WHAT ARE USER PERSPECTIVES OF EXOSKELETON TECHNOLOGY? A LITERATURE REVIEW

Exoskeleton-based exercises for overground gait and balance rehabilitation in spinal cord injury: a systematic review of dose and dosage parameters

BACKGROUND

Exoskeletons are increasingly applied during overground gait and balance rehabilitation following neurological impairment, although optimal parameters for specific indications are yet to be established.

OBJECTIVE

This systematic review aimed to identify dose and dosage of exoskeleton-based therapy protocols for overground locomotor training in spinal cord injury/disease.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items Systematic Reviews and Meta-Analyses guidelines. A literature search was performed using the CINAHL Complete, Embase, Emcare Nursing, Medline ALL, and Web of Science databases. Studies in adults with subacute and/or chronic spinal cord injury/disease were included if they reported (1) dose (e.g., single session duration and total number of sessions) and dosage (e.g., frequency of sessions/week and total duration of intervention) parameters, and (2) at least one gait and/or balance outcome measure.

RESULTS

Of 2,108 studies identified, after removing duplicates and filtering for inclusion, 19 were selected and dose, dosage and efficacy were abstracted. Data revealed a great heterogeneity in dose, dosage, and indications, with overall recommendation of 60-min sessions delivered 3 times a week, for 9 weeks in 27 sessions. Specific protocols were also identified for functional restoration (60-min, 3 times a week, for 8 weeks/24 sessions) and cardiorespiratory rehabilitation (60-min, 3 times a week, for 12 weeks/36 sessions).

CONCLUSION

This review provides evidence-based best practice recommendations for overground exoskeleton training among individuals with spinal cord injury/disease based on individual therapeutic goals - functional restoration or cardiorespiratory rehabilitation. There is a need for structured exoskeleton clinical translation studies based on standardized methods and common therapeutic outcomes.

"Are we there yet?" expectations and experiences with lower limb robotic exoskeletons: a qualitative evaluation of the therapist perspective

PURPOSE

Lower limb robotic exoskeletons can assist movement, however, clinical uptake in neurorehabilitation is limited. The views and experiences of clinicians are pivotal to the successful clinical implementation of emerging technologies. This study investigates therapist perspectives of the clinical use and future role of this technology in neurorehabilitation.

METHODS

Australian and New Zealand-based therapists with lower limb exoskeleton experience were recruited to complete an online survey and semi-structured interview. Survey data were transposed into tables and interviews transcribed verbatim. Qualitative data collection and analysis were guided by qualitative content analysis and interview data were thematically analysed.

RESULTS

Five participants revealed that the use of exoskeletons to deliver therapy involves the interplay of human elements - experiences and perspectives of use, and mechanical elements - the device itself. Two overarching themes emerged: the "journey", with subthemes of clinical reasoning and user experience; and the "vehicle" with design features and cost as subthemes, to explore the question "Are we there yet?"

CONCLUSION

Therapists expressed positive and negative perspectives from their experiences with exoskeletons, giving suggestions for design features, marketing input, and cost to enhance future use. Therapists are optimistic that this journey will see lower limb exoskeletons integral to rehabilitation service delivery.

Industrial practitioner's perception on the application of exoskeleton system in automotive assembly industries: A Malaysian case study

The automotive industry is a key manufacturing industry for the Malaysian economy, where manual jobs and task are still common. Hence, Work-related Musculoskeletal Disorders (WMSD) is a common type of injury among workers. Exoskeleton system has gained global traction as a possible solution to reduce the risk of MSD among workers. Nonetheless, the application of exoskeleton in the automotive industry in Malaysia remains unknown. As such, this study attempts to provide insight into the industry's perception on the potential of exoskeleton application within the context of Malaysian automotive assembly sector. Therefore, a total of 52 management level respondents from various manufacturers participated in this study. It is found that, although the technology seems to be relatively new and disruptive, the respondents have a positive perception towards it with an acceptance rate of 86.5%. Cost of implementation exoskeleton technologies seems to be primary concern from the respondents, other concern such as maintenance cost and ease of application into existing application is also highlighted.

Towards a validated glossary of usability attributes for the evaluation of wearable robotic devices

BACKGROUND

Despite technical advances in the field of wearable robotic devices (WRD), there is still limited user acceptance of these technologies. While usability often comes as a key factor influencing acceptance, there is a scattered landscape of definitions and scopes for the term. To advance usability evaluation, and to integrate usability features as design requirements during technology development, there is a need for benchmarks and shared terminology. These should be easily accessible and implementable by developers.

METHODS

An initial set of usability attributes (UA) was extracted from a literature survey on usability evaluation in WRD. The initial set of attributes was enriched and locally validated with seven developers of WRD through an online survey and a focus group. The locally validated glossary was then externally validated through a globally distributed online survey.

RESULTS

The result is the Robotics Usability Glossary (RUG), a comprehensive glossary of 41 UA validated by 70 WRD developers from 17 countries, ensuring its generalizability. 31 of the UA had high agreement scores among respondents and 27 were considered highly relevant in the field, but only 11 of them had been included as design criteria by the respondents.

CONCLUSIONS

Multiple UA ought to be considered for a comprehensive usability assessment. Usability remains inadequately incorporated into device development, indicating a need for increased awareness and end-user perspective. The RUG can be readily accessed through an online platform, the Interactive Usability Toolbox (IUT), developed to provide context-specific outcome measures and usability evaluation methods. Overall, this effort is an important step towards improving and promoting usability evaluation practices within WRD. It has the potential to pave the way for establishing usability evaluation benchmarks that further endorse the acceptance of WRD.

Exoskeleton Usability Questionnaire: a preliminary evaluation questionnaire for the lower limb industrial exoskeletons

Exoskeleton robots are a promising solution to reduce musculoskeletal disorders (MSDs) in different work environments, but a specific usability scale for evaluating them is lacking. This study aimed to develop and verify a preliminary Exoskeleton Usability Questionnaire (EUQ) for the lower limb exoskeletons by creating a draft survey questionnaire from existing questions in prior studies. An experiment was conducted with 20 participants who performed a specific task while wearing three lower limb robots and provided subjective feedback using the developed questionnaire. Data were analysed using exploratory and confirmatory factor analysis (CFA), resulting in a usability evaluation questionnaire for exoskeleton robots clustered into four main factors: mobility, adjustability, handling and safety. This study's findings are expected to be useful in evaluating the usability of the lower limb exoskeletons in both general production sites and agricultural work, which can aid in reducing the prevalence of lower limb MSDs.Practitioner Summary: This study developed a preliminary subjective usability evaluation questionnaire for exoskeleton robots. The questionnaire is clustered into four main factors: mobility, adjustability, handling and safety. These findings provide a valuable tool for assessing exoskeleton usability, potentially reducing musculoskeletal disorders (MSDs) in various work environments.

Exo Supportive Devices: Summary of Technical Aspects

Human societies have been trying to mitigate the suffering of individuals with physical impairments, with a special effort in the last century. In the 1950s, a new concept arose, finding similarities between animal exoskeletons, and with the goal of medically aiding human movement (for rehabilitation applications). There have been several studies on using exosuits with this purpose in mind. So, the current review offers a critical perspective and a detailed analysis of the steps and key decisions involved in the conception of an exoskeleton. Choices such as design aspects, base materials (structure), actuators (force and motion), energy sources (actuation), and control systems will be discussed, pointing out their advantages and disadvantages. Moreover, examples of exosuits (full-body, upper-body, and lower-body devices) will be presented and described, including their use cases and outcomes. The future of exoskeletons as possible assisted movement solutions will be discussed-pointing to the best options for rehabilitation.

A framework for evaluation and adoption of industrial exoskeletons

Work-related Musculoskeletal Disorders (WMSDs) account for a significant portion of worker illnesses and injuries, resulting in high costs and productivity losses to employers globally. In recent years, there has been an increased interest in the use of exoskeleton technology to reduce rates of WMSDs in industrial worksites. Despite the potential of exoskeletons to mitigate the risks of WMSDs, the required steps to properly assess and implement the technology for industrial applications are not clear. This paper proposes a framework that can help organizations successfully evaluate and adopt industrial exoskeletons. Through a focus group of industry professionals, researchers, and exoskeleton experts, and by building on existing literature, an overarching adoption framework is developed. The identified stages and tasks within the framework enable an organization to evaluate and adopt exoskeletons through a systematic approach and to identify the existing gaps in their technology adoption process. The findings also highlight the areas where further studies are needed to promote the adoption of industrial exoskeletons, including large-scale field studies and long-term monitoring.

A qualitative study to elicit user requirements for lower limb wearable exoskeletons for gait rehabilitation in spinal cord injury

OBJECTIVE

We aim to determine a comprehensive set of requirements, perceptions, and expectations that people with spinal cord injury (SCI) and the clinicians in charge of their rehabilitation have regarding the use of wearable robots (WR) for gait rehabilitation.

BACKGROUND

There are concerns due to the limited user acceptance of WR for gait rehabilitation. Developers need to emphasize understanding the needs and constraints of all stakeholders involved, including the real-life dynamics of rehabilitation centers.

METHODS

15 people with SCI, 9 without experience with WR and 6 with experience with these technologies, and 10 clinicians from 3 rehabilitation centers in Spain were interviewed. A directed content analysis approach was used.

RESULTS

78 codes grouped into 9 categories (physical results, usability, psychology-related codes, technical characteristics, activities, acquisition issues, context of use, development of the technologies and clinical rehabilitation context) were expressed by at least 20% of the users interviewed, of whom 16 were not found in the literature. The agreement percentage between each group and subgroup included in the study, calculated as the number of codes that more than 20% of both groups expressed, divided over the total amount of codes any of those two groups agreed on (≥ 20%), showed limited agreement between patients and clinicians (50.00%) and between both types of patients (55.77%). The limited accessibility and availability of lower limb exoskeletons for gait rehabilitation arose in most of the interviews.

CONCLUSIONS

The limited agreement percentage between patients and clinicians indicates that including both types of users in the design process of these technologies is important, given that their requirements are complementary. Engaging users with prior technology experience is recommended, as they often exhibit strong internal consensus and articulate well-defined requirements. This study adds up the knowledge available in the literature and the new codes found in our data, which enlighten important aspects that ought to be addressed in the field to develop technologies that respond to users' needs, are usable and feasible to implement in their intended contexts.

APPLICATION

The set of criteria summarized in our study will be useful to guide the design, development, and evaluation of WR for gait rehabilitation to meet user's needs and allow them to be implemented in their intended context of use.

Lower extremity robotic exoskeleton devices for overground ambulation recovery in acquired brain injury-A review

Acquired brain injury (ABI) is a leading cause of ambulation deficits in the United States every year. ABI (stroke, traumatic brain injury and cerebral palsy) results in ambulation deficits with residual gait and balance deviations persisting even after 1 year. Current research is focused on evaluating the effect of robotic exoskeleton devices (RD) for overground gait and balance training. In order to understand the device effectiveness on neuroplasticity, it is important to understand RD effectiveness in the context of both downstream (functional, biomechanical and physiological) and upstream (cortical) metrics. The review identifies gaps in research areas and suggests recommendations for future research. We carefully delineate between the preliminary studies and randomized clinical trials in the interpretation of existing evidence. We present a comprehensive review of the clinical and pre-clinical research that evaluated therapeutic effects of RDs using various domains, diagnosis and stage of recovery.

Assessment of Exoskeletons on Nurses' Quality of Work Life: A Pilot Study at Foch Hospital

BACKGROUND

The prevention of occupational risks is part of the quality of work life and it is a component that improves the physical work environment. The purpose of the present study was to investigate how to maintain posture and to reduce pain and fatigue for nurses, with an exoskeleton adapted to the work at hospital.

METHODS

The exoskeleton was used between 2022 to 2023 at Foch Hospital, France. Phase 1 consisted of the selection of the exoskeleton, and Phase 2 included the testing of the device by the nurses and a questionnaire to assess it.

RESULTS

The "active" ATLAS model from JAPET, ensuring lumbar protection, was selected because it corresponds to all the specification criteria to tackle the nurses' unmet need. Among the 14 healthcare professionals, 86% were women; the age of the nurses was between 23 years old and 58 years old. The global median satisfaction score of the nurses relative to the use of the exoskeleton was 6/10. The median impact of the exoskeleton on nurses' fatigue was 7/10.

CONCLUSIONS

The implementation of the exoskeleton received global positive qualitative feedback from the nurses concerning the improvement of posture and the reduction in fatigue and pain.

Satisfaction analysis of overground gait exoskeletons in people with neurological pathology. a systematic review

BACKGROUND

People diagnosed with neurological pathology may experience gait disorders that affect their quality of life. In recent years, research has been carried out on a variety of exoskeletons in this population. However, the satisfaction perceived by the users of these devices is not known. Therefore, the objective of the present study is to evaluate the satisfaction perceived by users with neurological pathology (patients and professionals) after the use of overground exoskeletons.

METHODS

A systematic search of five electronic databases was conducted. In order to be included in this review for further analysis, the studies had to meet the following criteria: [1] the study population was people diagnosed with neurological pathology; [2] the exoskeletons had to be overground and attachable to the lower limbs; and [3]: the studies were to include measures assessing either patient or therapist satisfaction with the exoskeletons.

RESULTS

Twenty-three articles were selected, of which nineteen were considered clinical trials. Participants diagnosed with stroke (n = 165), spinal cord injury (SCI) (n = 102) and multiple sclerosis (MS) (n = 68). Fourteen different overground exoskeleton models were analysed. Fourteen different methods of assessing patient satisfaction with the devices were found, and three ways to evaluate it in therapists.

CONCLUSION

Users' satisfaction with gait overground exoskeletons in stroke, SCI and MS seems to show positive results in safety, efficacy and comfort of the devices. However, the worst rated aspects and therefore those that should be optimized from the users' point of view are ease of adjustment, size and weight, and ease of use.

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.

Design recommendations for exoskeletons: Perspectives of individuals with spinal cord injury

OBJECTIVE

This study investigated the expectations of individuals with spinal cord injury (SCI) regarding exoskeletons.

DESIGN

The survey consisted out of questions regarding multiple aspects of exoskeleton technology.

SETTING

An online survey was distributed via the monthly newsletter of the Dutch Patient Association for Spinal Cord Injury (SCI).

PARTICIPANTS

Individuals with SCI who are members of the Dutch Patient Association for SCI.

OUTCOME MEASURES

General impression of exoskeleton technology, expectations regarding capabilities and user-friendliness, training expectations and experiences, future perspectives and points of improvement.

RESULTS

The survey was filled out by 95 individuals with SCI, exoskeletons were considered positive and desirable by 74.7%. About 11 percent (10.5%) thought one could ambulate faster, or just as fast, while wearing an exoskeleton as able-bodied people. Furthermore, 18.9% expected not to use a wheelchair or walking aids while ambulating with the exoskeleton. Twenty-five percent believed that exoskeletons could replace wheelchairs. Some main points of improvement included being able to wear the exoskeleton in a wheelchair and while driving a car, not needing crutches while ambulating, and being able to put the exoskeleton on by oneself.

CONCLUSION

Individuals with SCI considered exoskeletons as a positive and desirable innovation. But based on the findings from the surveys, major points of improvement are necessary for exoskeletons to replace wheelchairs in the future. For future exoskeleton development, we recommend involvement of individuals with SCI to meet user expectations and improve in functionality, usability and quality of exoskeletons.

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.

Design and validation of a novel online platform to support the usability evaluation of wearable robotic devices

Wearable robotic devices (WRD) are still struggling to fulfill their vast potential. Inadequate daily life usability is one of the main hindrances to increased technology acceptance. Improving usability evaluation practices during the development of WRD could help address these limitations. In this work, we present the design and validation of a novel online platform aiming to fill this gap, the Interactive Usability Toolbox (IUT). This platform consists of a public website that offers an interactive, context-specific search within a database of 154 user research methods and educational information about usability. In a dedicated study, the effect of this platform to support usability evaluation was investigated. Twelve WRD experts were asked to complete the task of defining usability evaluation protocols for two specific use cases. The platform was provided to support one of the use cases. The quality and composition of the proposed protocols were assessed by (i) two blinded reviewers, (ii) the participants themselves, and (iii) the study coordinators. We showed that using the IUT significantly affected the proposed evaluation focus, shifting protocols from mainly effectiveness-oriented to more user-focused studies. The protocol quality, as rated by the external reviewers, remained equivalent to those designed with conventional strategies. A mixed-method usability evaluation of the platform yielded an overall positive image, with detailed suggestions for further improvements. The IUT is expected to positively affect the evaluation and development of WRD through its educational value, the context-specific recommendations supporting ongoing benchmarking endeavors, and highlighting the value of qualitative user research.

IMU-based human activity recognition and payload classification for low-back exoskeletons

Nowadays, work-related musculoskeletal disorders have a drastic impact on a large part of the world population. In particular, low-back pain counts as the leading cause of absence from work in the industrial sector. Robotic exoskeletons have great potential to improve industrial workers' health and life quality. Nonetheless, current solutions are often limited by sub-optimal control systems. Due to the dynamic environment in which they are used, failure to adapt to the wearer and the task may be limiting exoskeleton adoption in occupational scenarios. In this scope, we present a deep-learning-based approach exploiting inertial sensors to provide industrial exoskeletons with human activity recognition and adaptive payload compensation. Inertial measurement units are easily wearable or embeddable in any industrial exoskeleton. We exploited Long-Short Term Memory networks both to perform human activity recognition and to classify the weight of lifted objects up to 15 kg. We found a median F1 score of [Formula: see text] (activity recognition) and [Formula: see text] (payload estimation) with subject-specific models trained and tested on 12 (6M-6F) young healthy volunteers. We also succeeded in evaluating the applicability of this approach with an in-lab real-time test in a simulated target scenario. These high-level algorithms may be useful to fully exploit the potential of powered exoskeletons to achieve symbiotic human-robot interaction.

Usability of an exosuit in domestic and community environments

BACKGROUND

Exosuits have been shown to reduce metabolic cost of walking and to increase gait performance when used in clinical environment. Currently, these devices are transitioning to private use to facilitate independent training at home and in the community. However, their acceptance in unsupervised settings remains unclear. Therefore, the aim of this study was to investigate end-user perspectives and the adoption of an exosuit in domestic and community settings.

METHODS

We conducted a mixed-method study to investigate the usability and user experience of an exosuit, the Myosuit. We leveraged on a cohort of seven expert users, who had the device available at home for at least 28 days. Each participant completed two standardized questionnaires (SUS and QUEST) and one personalized, custom questionnaire. Furthermore, a semi-structured interview with each participant was recorded, verbatim transcribed and analyzed using descriptive thematic analysis. Data collected from device sensors quantified the frequency of use.

RESULTS

A mean SUS score of 75.4 out of 100 was reported. Five participants scored above the threshold for above-average usability. Participants also expressed high satisfaction with most of the technical features in the QUEST with an average score of 4.1 (3.86-4.71) out of 5. Participants used the Myosuit mainly for walking outside and exercising at home. However, the frequency of use did not meet the recommendations for physical activity established by the World Health Organization. Five participants used the Myosuit approximately once per week. The two other participants integrated the device in their daily life and used the Myosuit to a greater extent (approx. five times per week). Major factors that prevented an extensive use of the technology were: (i) difficulties in donning that led to (ii) lack of independence and (iii) lack of motivation in exercising.

CONCLUSIONS

Although usable for various activities and well perceived, the adoption of the exosuit in domestic and community settings is yet limited. Use outside the clinic poses further challenges that should be considered when developing new wearable robots. Primarily, design should meet the users' claim for independence and increased adjustability of the device.

Patients' and therapists' experience and perception of exoskeleton-based physiotherapy during subacute stroke rehabilitation: a qualitative analysis

PURPOSE

To explore the experience and acceptability of an exoskeleton-based physiotherapy program for non-ambulatory patients during subacute stroke rehabilitation from the perspective of patients and therapists.

MATERIALS AND METHODS

This was a qualitative descriptive study using semi-structured interviews and thematic analysis. Fourteen patients with stroke who participated in the experimental arm of a randomized controlled trial investigating the efficacy of exoskeleton-based physiotherapy were recruited. Six physiotherapists who provided the intervention were also recruited.

RESULTS

Three themes were identified relating to the experience and acceptability of an exoskeleton-based physiotherapy program: (1) A matter of getting into the swing of things depicted the initial and ongoing learning process of using an exoskeleton; (2) More of a positive experience than anything else described the participants' mostly favorable attitude toward exoskeleton-based gait training; and (3) The best step forward captured participant-identified recommendations and considerations for the future integration of exoskeleton training into stroke rehabilitation.

CONCLUSIONS

Patients with stroke were even more optimistic than therapists toward the experience and benefits of exoskeleton-based gait training during subacute stroke rehabilitation. Future clinical practice should consider the balance between actual and perceived benefits, as well as the potential barriers to integrating an exoskeleton into stroke rehabilitation.IMPLICATIONS FOR REHABILITATIONPowered robotic exoskeletons can be used to provide higher duration and more repetitious walking practice for non-ambulatory patients with stroke.Patients with stroke view exoskeleton-based physiotherapy highly favorably, attributing greater opportunity and benefit to using the device during subacute rehabilitation.Physiotherapists should consider learning challenges, patient characteristics, and implementation barriers when integrating exoskeleton-based training within a treatment program.

User-centered design and development of TWIN-Acta: A novel control suite of the TWIN lower limb exoskeleton for the rehabilitation of persons post-stroke

Introduction

Difficulties faced while walking are common symptoms after stroke, significantly reducing the quality of life. Walking recovery is therefore one of the main priorities of rehabilitation. Wearable powered exoskeletons have been developed to provide lower limb assistance and enable training for persons with gait impairments by using typical physiological movement patterns. Exoskeletons were originally designed for individuals without any walking capacities, such as subjects with complete spinal cord injuries. Recent systematic reviews suggested that lower limb exoskeletons could be valid tools to restore independent walking in subjects with residual motor function, such as persons post-stroke. To ensure that devices meet end-user needs, it is important to understand and incorporate their perspectives. However, only a limited number of studies have followed such an approach in the post-stroke population.

Methods

The aim of the study was to identify the end-users needs and to develop a user-centered-based control system for the TWIN lower limb exoskeleton to provide post-stroke rehabilitation. We thus describe the development and validation, by clinical experts, of TWIN-Acta: a novel control suite for TWIN, specifically designed for persons post-stroke. We detailed the conceived control strategy and developmental phases, and reported evaluation sessions performed on healthy clinical experts and people post-stroke to evaluate TWIN-Acta usability, acceptability, and barriers to usage. At each developmental stage, the clinical experts received a one-day training on the TWIN exoskeleton equipped with the TWIN-Acta control suite. Data on usability, acceptability, and limitations to system usage were collected through questionnaires and semi-structured interviews.

Results

The system received overall good usability and acceptability ratings and resulted in a well-conceived and safe approach. All experts gave excellent ratings regarding the possibility of modulating the assistance provided by the exoskeleton during the movement execution and concluded that the TWIN-Acta would be useful in gait rehabilitation for persons post-stroke. The main limit was the low level of system learnability, attributable to the short-time of usage. This issue can be minimized with prolonged training and must be taken into consideration when planning rehabilitation.

Discussion

This study showed the potential of the novel control suite TWIN-Acta for gait rehabilitation and efficacy studies are the next step in its evaluation process.

A Review of Exoskeletons Considering Nurses

Daily tasks of nurses include manual handling to assist patients. Repetitive manual handling leads to high risk of injuries due to the loads on nurses' bodies. Nurses, in hospitals and care homes, can benefit from the advances in exoskeleton technology assisting their manual handling tasks. There are already exoskeletons both in the market and in the research area made to assist physical workers to handle heavy loads. However, those exoskeletons are mostly designed for men, as most physical workers are men, whereas most nurses are women. In the case of nurses, they handle patients, a more delicate task than handling objects, and any such device used by nurses should easily be disinfected. In this study, the needs of nurses are examined, and a review of the state-of-the-art exoskeletons is conducted from the perspective of to what extent the existing technologies address the needs of nurses. Possible solutions and technologies and particularly the needs that have not been addressed by the existing technologies are discussed.

User Based Development and Test of the EXOTIC Exoskeleton: Empowering Individuals with Tetraplegia Using a Compact, Versatile, 5-DoF Upper Limb Exoskeleton Controlled through Intelligent Semi-Automated Shared Tongue Control

This paper presents the EXOTIC- a novel assistive upper limb exoskeleton for individuals with complete functional tetraplegia that provides an unprecedented level of versatility and control. The current literature on exoskeletons mainly focuses on the basic technical aspects of exoskeleton design and control while the context in which these exoskeletons should function is less or not prioritized even though it poses important technical requirements. We considered all sources of design requirements, from the basic technical functions to the real-world practical application. The EXOTIC features: (1) a compact, safe, wheelchair-mountable, easy to don and doff exoskeleton capable of facilitating multiple highly desired activities of daily living for individuals with tetraplegia; (2) a semi-automated computer vision guidance system that can be enabled by the user when relevant; (3) a tongue control interface allowing for full, volitional, and continuous control over all possible motions of the exoskeleton. The EXOTIC was tested on ten able-bodied individuals and three users with tetraplegia caused by spinal cord injury. During the tests the EXOTIC succeeded in fully assisting tasks such as drinking and picking up snacks, even for users with complete functional tetraplegia and the need for a ventilator. The users confirmed the usability of the EXOTIC.

A Novel Mixed-Method Approach to Identify Needs and Requirements for Upper Limb Assistive Technology for Persons after Stroke

Following stroke, a significant portion of individuals suffer from upper limb impairments and struggle with activities of daily living. Dedicated assistive technology (AT), such as robotic hand orthoses (RHO), can help facilitate upper limb usage and allow users to regain independence in their daily lives. Often, users' needs and requirements are neglected in AT design, thereby contributing to poor technology acceptance. In this work, we propose and apply a mixed-method focus group combining qualitative and quantitative components to gather user expectations in view of a user-centred redesign of a RHO. Three main themes emerged from a thematic analysis of two focus groups (n=5): Experience after stroke, desired design features, and reflections and realisations. Participants listed device features they would look for in AT and ranked them relative to what they deem important and necessary for a satisfactory device. Participants primarily looked for AT that is effective, intuitive and easy to use. These insights complement traditional technical design requirements for RHO by considering user desires, aspects unfortunately often neglected in the early design process. This work provides guidelines allowing for the optimization of AT design to better match the needs of persons after stroke and improve technology acceptance.

Subjective Response Measurement to Prosthesis or Device Use: Validation of the Prosthetic-Bionic Paradigm Questionnaire (PBP-Q)

Many subjects with somatic pathologies or traumas in their recent anamnesis tend to experience symptoms and changes to their daily life parameters after technically successful treatment. Hence, this study aims to validate an investigation tool inspired by the prosthetic-bionic paradigm-namely, the PBP-Q-which allows for the evaluation of variation in questions relating to identity, psychosociality, and psychopathology in relation to the use of a prosthesis or device. We gathered 118 participants (68 females and 50 males) aged between 27 and 94 years (Mean = 58.42 ± 15.17). We performed both exploratory (EFA) and confirmatory (CFA) factor analyses on this sample. Moreover, we calculated the internal consistency for the PBP-Q scales and the total score for the questionnaire's final 26-item and 5-factor versions. The five scales are psychological well-being; interpersonal relationships; professional relationships; autonomy and safety; addictions, compulsions, and obsessions. The internal consistency is good for both the total score and the subscales. In conclusion, overall, the PBP-Q has satisfactory psychometric properties, especially considering the measure's complexity. It provides a quick and effective way to evaluate the changes that might arise after the use of a prosthesis or device and, subsequently, has implications for clinical practice.

A survey on the influence of CYBATHLON on the development and acceptance of advanced assistive technologies

Background

Advanced assistive technologies (AAT) aim to exploit the vast potential of technological developments made in the past decades to improve the quality of life of people with disabilities. Combining complex robotic technologies with the unique needs of people with disabilities requires a strong focus on user-centered design to ensure that the AAT appropriately addresses the daily life struggles of target users. The CYBATHLON aims to promote this mindset by empowering the AAT target users (“pilots”) to compete on race tracks that represent approximations of daily life obstacles. The objective of this work was to investigate the AAT technology development, usability, and user involvement (i.e., application of user-centered design) in the context of the CYBATHLON.

Methods

With an online survey targeting the pilots and technical leads of teams preparing for the CYBATHLON 2020 Global Edition, we investigated to what extent the pilots were involved in device development and how this influences the perceived usability of the showcased AAT. Furthermore, the effects of user-centered design variables on the individual race performances were analyzed.

Results

A total of 81 responses from 35 pilots and 46 technical leads were collected in the two weeks prior to the event. Of all teams partaking in the included disciplines of the CYBATHLON 2020 Global Edition, 81.8% (36 of 44) were included in the study. User-centered design appeared to be a prevalent practice among the teams, as 85.7% of all pilots reported a certain level of involvement. However, only 25.5% of the pilots reported daily life usage, despite QUEST usability scores of both respondent groups showing moderate to high satisfaction with the respected AAT across all investigated disciplines. An explorative linear mixed model indicated that daily life usage (p < 0.05) and prolonged user involvement (e.g., more than 2 years, p < 0.001) have a significant positive effect on the race performance at the competition.

Conclusions

We conclude that the CYBATHLON positively fulfills its conceptual goals of promoting active participation and inclusion of people with disabilities in the design and evaluation of AAT, thereby stimulating the development of promising novel technological solutions. Also, our data could underline the value of the competition as a benchmark, highlighting remaining usability limitations or technology adoption hurdles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01015-5.

User perspectives on the future of mobility assistive devices: Understanding users’ assistive device experiences and needs

Introduction

Current assistive devices are inadequate in addressing the needs of some people living with impaired mobility. This study explored the experiences of living with impaired mobility in relation to how wearable assistive adaptive and rehabilitative technologies may improve their quality of life.

Methods

A cross-case study approach was adopted; the case being defined as the experience of impaired mobility. Semi-structured interviews were utilised. The sample ( n = 8) was purposefully selected to have impaired mobility due to stroke, age-related frailty, or lower limb amputation. From the interview transcripts, in-depth case illustrations were written to provide personal stories and thematic analysis was carried out to provide a cross-case analysis.

Results

There were two overarching themes: lifestyle changes; and wishes and desires for assistive devices. There were shared experiences across participant groups, such as falls and fear of falling. All participants identified a wish for increased speed of walking. However, the reasons for their difficulties differed depending on personal factors and their condition. Participants wanted devices to be adjustable to their perceived ability on a day-to-day basis.

Conclusions

Although common concerns and impacts of living with impaired mobility were apparent, individuals have unique requirements that should inform the design of assistive technology devices.

An analysis of usability evaluation practices and contexts of use in wearable robotics

BACKGROUND

User-centered design approaches have gained attention over the past decade, aiming to tackle the technology acceptance issues of wearable robotic devices to assist, support or augment human capabilities. While there is a consensus that usability is key to user-centered design, dedicated usability evaluation studies are scarce and clear evaluation guidelines are missing. However, the careful consideration and integration of user needs appears to be essential to successfully develop an effective, efficient, and satisfactory human-robot interaction. It is primarily the responsibility of the developer, to ensure that this users involvement takes place throughout the design process.

METHODS

Through an online survey for developers of wearable robotics, we wanted to understand how the design and evaluation in actual daily practice compares to what is reported in literature. With a total of 31 questions, we analyzed the most common wearable robotic device applications and their technology maturity, and how these influence usability evaluation practices.

RESULTS

A total of 158 responses from a heterogeneous population were collected and analyzed. The dataset representing contexts of use for augmentation (16.5%), assistance (38.0%), therapy (39.8%), as well as few other specific applications (5.7%), allowed for an insightful analysis of the influence of technology maturity on user involvement and usability evaluation. We identified functionality, ease of use, and performance as the most evaluated usability attributes and could specify which measures are used to assess them. Also, we could underline the frequent use of qualitative measures alongside the expected high prevalence of performance-metrics. In conclusion of the analysis, we derived evaluation recommendations to foster user-centered design and usability evaluation.

CONCLUSION

This analysis might serve as state-of-the-art comparison and recommendation for usability studies in wearable robotics. We believe that by motivating for more balanced, comparable and user-oriented evaluation practices, we may support the wearable robotics field in tackling the technology acceptance limitations.

A review of innovation strategies and processes to improve access to AT: Looking ahead to open innovation ecosystems

It is essential to understand the strategies and processes which are deployed currently across the Assistive Technology (AT) space toward measuring innovation. The main aim of this paper is to identify functional innovation strategies and processes which are being or can be deployed in the AT space to increase access to AT globally. We conducted a scoping review of innovation strategies and processes in peer-reviewed literature databases and complemented this by identifying case studies demonstrating innovation strategies. The review includes WHO world region, publication year, AT type and a sector analysis against the Systems-Market for Assistive and Related Technologies Framework. We analyzed the case studies and interviews using thematic analysis. We included 91 papers out of 3,127 after review along with 72 case studies. Our results showed that product innovations were more prevalent than provision or supply innovations across papers and case studies. Case studies yielded two themes: open innovation (OI); radical and disruptive innovation. Financial instruments which encourage OI are needed and we recommend pursuing OI for AT innovation. Embedding AT within larger societal missions will be key to success governments and investors need to understand what AT is and their translational socioeconomic value.

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.

Integration and Testing of a High-Torque Servo-Driven Joint and Its Electronic Controller with Application in a Prototype Upper Limb Exoskeleton

Mechatronic systems that allow motorized activation in robotic exoskeletons have evolved according to their specific applications and the characteristics of the actuation system, including parameters such as size, mechanical properties, efficiency, and power draw. Additionally, different control strategies and methods could be implemented in various electronic devices to improve the performance and usability of these devices, which is desirable in any application. This paper proposes the integration and testing of a high-torque, servo-driven joint and its electronic controller, exposing its use in a robotic exoskeleton prototype as a case study. Following a brief background review, the development and implementation of the proposal are presented, allowing the control of the servo-driven joint in terms of torque, rotational velocity, and position through a straightforward, closed-loop control architecture. Additionally, the stability and performance of the servo-driven joint were assessed with and without load. In conclusion and based on the obtained results, the servo-driven joint and its control system demonstrate consistent performance under the proposed test protocol (max values: angular velocity 97 °/s, torque 33 Nm, positioning RMSE 1.46°), enabling this approach for use in various applications related to robotic exoskeletons, including human performance enhancement, rehabilitation, or support for daily living activities.

Assessment Methods of Usability and Cognitive Workload of Rehabilitative Exoskeletons: A Systematic Review

Robotic exoskeleton technologies are applied in the medical field to help patients with impaired mobility to recover their motor functions. Relevant literature shows that usability and cognitive workload may influence the patients’ likelihood to benefit from the use of rehabilitative exoskeletons. Following the PRISMA method, the present study aimed to systematically review the assessment methods of usability and cognitive workload in the use of exoskeletal devices for motor rehabilitation. The literature search was conducted in the Scopus and Web of Science bibliographical databases, using 16 keywords that were combined into one search query. A final sample of 23 articles was included in the review, from which 18 distinct assessment methods were identified. Of them, 15 aimed to assess usability, whereas 3 aimed to assess cognitive workload in the use of rehabilitative exoskeletons. Some of the identified methods (e.g., SUS, QUEST, SWAT, and NASA-TLX) showed good psychometric properties and were therefore proven to be appropriate to assess usability and cognitive workload while performing exoskeleton-based rehabilitation. The current study may contribute to the development of guidelines and analytical tools for exoskeletons’ usability and exoskeleton-related patients’ cognitive workload in the domain of medical rehabilitation.

Are Functional Measures Sufficient to Capture Acceptance? A Qualitative Study on Lower Limb Exoskeleton Use for Older People

Lower limb exoskeletons (LLE) are robotic devices developed to assist walk. In the field of healthcare, this technology has been available for almost a decade, yet it still faces important acceptance issues. While LLE were first developed for patients with spinal cord injuries, we expect their use to expand to everyday settings to benefit other populations, namely that of older people with reduced mobility (RM). We propose a qualitative approach to unearth key psychosocial themes on the acceptance of LLE in daily living for older people. The study analyses perceptions of older people with RM, as well as their entourage, including informal and professional caregivers. Using a grounded theory approach we analysed 12 semi-structured interviews with older people with RM; 2 focus groups with informal caregivers, and 2 focus groups with professional caregivers. LLE were introduced to participants through photo-elicitation. Older people with RM believed that LLE would increase their autonomy. They also perceived that using LLE would make them feel less of a burden for their entourage. Beyond these expected benefits, results captured participants’ ambivalence, dependent on their experiences of the ageing process and perceptions on the human–machine interaction. Informal caregivers highlighted that LLE could provide important relief related to the burden of care. Nonetheless, professional caregivers raised the fear of LLE leading to dehumanization of care. While each group had specific concerns on how LLE use would impact their lives, psychosocial considerations played a key role in LLE acceptance.

Design of a Payload Adjustment Device for an Unpowered Lower-Limb Exoskeleton

This paper proposes a device that can change the payload of an unpowered lower-limb exoskeleton supporting the weights of humans and loads. Our previous exoskeletons used a cam–follower structure with a spring applied to the hip joint. This exoskeleton showed satisfying performance within the payload; however, the performance decreased when the payload was exceeded. Therefore, a payload adjustment device that can adjust the wearer’s required torque by easily applying it to the cam–follower structure was developed. An exoskeleton dynamic equation that can calculate a person’s required joint torque given the required payload and the wearer’s posture was derived. This dynamic equation provides a guideline for designing a device that can adjust the allowable joint torque range of an unpowered exoskeleton. In the Adams simulation environment, the payload adjustment device is applied to the cam–follower structure to show that the payload of the exoskeleton can be changed. User convenience and mass production were taken into account in the design of this device. This payload adjustment device should flexibly change the payload of the level desired by the wearer because it can quickly change the payload of the exoskeleton.

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.

Passive Trunk Exoskeleton Acceptability and Effects on Self-efficacy in Employees with Low-Back Pain: A Mixed Method Approach

Purpose Determinants of successfully introducing passive exoskeletons in the working environment to decrease mechanical loading on the back, are acceptability of the device to management and employees, including self-efficacy of employees when using the device. Therefore, the aim of this study was to assess self-efficacy of employees with low-back pain when using an exoskeleton and the acceptability of such a device to these employees and their managers. Methods We used a mixed method approach. We quantitatively assessed the change in self-efficacy of 17 employees with low-back pain when performing daily activity tasks with the exoskeleton, using the modified spinal function sort (M-SFS). Qualitatively, we conducted a focus group with employees and a double interview with two managers to add more insight and understandings into changes in self-efficacy and to discuss challenges of implementing an exoskeleton in the working environment. Results Self-efficacy significantly increased by 7% when using the exoskeleton. Employees acknowledged the flexibility of the exoskeleton being advantageous to current static external lifting devices, which confirmed the increase of self-efficacy in both static and dynamic tasks. Individual data showed that the increase in self-efficacy was largest for participants, being greatly restricted by their low-back pain. In the focus group, employees confirmed that they are mostly open to wearing the exoskeleton if they suffer from low-back pain. Conclusion If potential challenges, e.g. visibility and potential refusal of wearing an exoskeleton are considered in the implementation strategy, acceptability of and self-efficacy in using the passive trunk exoskeleton would be further improved, potentially contributing to reduced risk of low-back pain.

Short-Term Effects of a Passive Spinal Exoskeleton on Functional Performance, Discomfort and User Satisfaction in Patients with Low Back Pain

Purpose Low back pain (LBP) remains a major worldwide healthcare issue. Recently, spinal exoskeletons were proposed as a potentially useful solution for LBP prevention and vocational reintegration for people who perform heavy load lifting, repetitive movements or work in prolonged static postures. The purpose of this study was to investigate how patients with LBP respond to the novel passive SPEXOR exoskeleton regarding functional performance, discomfort and general user impression. Methods Fourteen patients, with low to moderate LBP (2-7 on a 0-10 scale), performed 12 functional tasks with and without the exoskeleton. In addition to objective performance measures, participants subjectively assessed the level of local low back discomfort, task difficulty and general discomfort on a 0-10 visual analogue scales. Results The SPEXOR exoskeleton had favourable effects on performance and local discomfort during prolonged static forward bending. Minor reductions in performance were observed for sit-stand and ladder climbing tasks. The discomfort associated with the exoskeleton was generally low to moderate (median < 4), except for the 6-min walk test (median = 4.5), which is likely due to the weight of the device and obstruction of upper limb movement. The general impressions were mostly positive, with good adjustability, low interference with the movement and moderate support reported by the participants. Conclusion The SPEXOR exoskeleton is potentially useful for LBP prevention or management, however, further improvements are needed to provide higher levels support during heavy load lifting.

Exoskeleton use in post-stroke gait rehabilitation: a qualitative study of the perspectives of persons post-stroke and physiotherapists

Background

Wearable powered exoskeletons are a new and emerging technology developed to provide sensory-guided motorized lower limb assistance enabling intensive task specific locomotor training utilizing typical lower limb movement patterns for persons with gait impairments. To ensure that devices meet end-user needs it is important to understand and incorporate end-users perspectives, however research in this area is extremely limited in the post-stroke population. The purpose of this study was to explore in-depth, end-users perspectives, persons with stroke and physiotherapists, following a single-use session with a H2 exoskeleton.

Methods

We used a qualitative interpretive description approach utilizing semi-structured face to face interviews, with persons post-stroke and physiotherapists, following a 1.5 h session with a H2 exoskeleton.

Results

Five persons post-stroke and 6 physiotherapists volunteered to participate in the study. Both participant groups provided insightful comments on their experience with the exoskeleton. Four themes were developed from the persons with stroke participant data: (1) Adopting technology; (2) Device concerns; (3) Developing walking ability; and, (4) Integrating exoskeleton use. Five themes were developed from the physiotherapist participant data: (1) Developer-user collaboration; (2) Device specific concerns; (3) Device programming; (4) Patient characteristics requiring consideration; and, (5) Indications for use.

Conclusions

This study provides an interpretive understanding of end-users perspectives, persons with stroke and neurological physiotherapists, following a single-use experience with a H2 exoskeleton. The findings from both stakeholder groups overlap such that four over-arching concepts were identified including: (i) Stakeholder participation; (ii) Augmentation vs. autonomous robot; (iii) Exoskeleton usability; and (iv) Device specific concerns. The end users provided valuable perspectives on the use and design of the H2 exoskeleton, identifying needs specific to post-stroke gait rehabilitation, the need for a robust evidence base, whilst also highlighting that there is significant interest in this technology throughout the continuum of stroke rehabilitation.

Reliability of a battery of tests for functional evaluation of trunk exoskeletons

Recently, several spinal exoskeletons were developed with the aim to assist occupational tasks such as load-handling and work in prolonged static postures. While the biomechanical effects of such devices has been well investigated, only limited feedback to the developers is usually provided regarding the subjective perceptions of the end-users. The aim of this study was to present a novel battery of tests, designed to assess functional performance and subjective outcomes during the use of assistive trunk exoskeletons, and to assess its test-retest reliability. The battery of tests consists of 12 different simple functional tasks. Twenty participants were included in an intra-session reliability test and repeated the tests within 7-10 days to assess inter-session reliability. They were wearing a novel passive spinal exoskeleton during all trials. The outcomes included quantitative and subjective measures, such as performance time and rating of discomfort and perceived task difficulty. The majority of the outcome measures were reliable within session and between sessions (ICC or α > 0.80). Systematic effects were observed in a few tasks, suggesting that familiarization trials will be needed to minimize the learning effects. The novel battery of tests could become an important easy-to-use tool for functional testing of the spinal exoskeletons in addition to more specific biomechanical and physiological testing. Further studies should address the reliability of the present battery of tests for assessing specific populations, such as low back pain patients and explore how to minimize systematic effects that were observed in this study.

Assessing the Involvement of Users During Development of Lower Limb Wearable Robotic Exoskeletons: A Survey Study

OBJECTIVE

To explore user-centered design methods currently implemented during development of lower limb wearable robots and how they are utilized during different stages of product development.

BACKGROUND

Currently, there appears to be a lack of standardized frameworks for evaluation methods and design requirements to implement effective user-centered design for safe and effective clinical or ergonomic system application.

METHOD

Responses from a total of 191 experts working in the field of lower limb exoskeletons were analyzed in this exploratory survey. Descriptive statistics were used to present responses and measures of frequency, and chi-square tests were used to contrast the answers of respondents who identified as clinicians versus engineers.

RESULTS

A vast majority of respondents involve users in their development, in particular at the initial and iterative stages, although some differences were found between disciplines. A variety of methods and metrics are used to capture feedback from users and test devices, and although valuable, some methods used may not be based on validated measures. Guidelines regarding tests on safety of exoskeletons also lack standardization.

CONCLUSION

There seems to be a consensus among experts regarding the importance of a user-centered approach in exoskeleton development; however, standardized frameworks with regard to appropriate testing methods and design approaches are lacking. Such frameworks should consider an interdisciplinary focus on the needs and safety of the intended user during each iteration of the process.

APPLICATION

This exploratory study provides an overview of current practice among engineers and clinicians regarding the user-centered design of exoskeletons. Limitations and recommendations for future directions are identified.

Perspectives of End Users on the Potential Use of Trunk Exoskeletons for People With Low-Back Pain: A Focus Group Study

OBJECTIVE

The objective of this study was to identify criteria to be considered when developing an exoskeleton for low-back pain patients by exploring the perceptions and expectations of potential end users.

BACKGROUND

Psychosocial, psychological, physical load, and personality influence incidence of low-back pain. Body-worn assistive devices that passively support the user's trunk, that is exoskeletons, can decrease mechanical loading and potentially reduce low-back pain. A user-centered approach improves patient safety and health outcomes, increases user satisfaction, and ensures usability. Still, previous studies have not taken psychological factors and the early involvement of end users into account.

METHOD

We conducted focus group studies with low-back pain patients (n = 4) and health care professionals (n = 8). Focus group sessions were audio-recorded, transcribed, and analyzed, using the general inductive approach. The focus group discussions included trying out an available exoskeleton. Questions were designed to elicit opinions about exoskeletons, desired design specifications, and usability.

RESULTS

Important design characteristics were comfort, individual adjustability, independency in taking it on and off, and gradual adjustment of support. Patients raised concerns over loss of muscle strength. Health care professionals mentioned the risk of confirming disability of the user and increasing guarded movement in patients.

CONCLUSION

The focus groups showed that implementation of a trunk exoskeleton to reduce low-back pain requires an adequate implementation strategy, including supervision and behavioral coaching.

APPLICATION

For health care professionals, the optimal field of application, prevention or rehabilitation, is still under debate. Patients see potential in an exoskeleton to overcome their limitations and expect it to improve their quality of life.

"Back at the same level as everyone else"-user perspectives on walking with an exoskeleton, a qualitative study

Study design

Qualitative, in-depth research interviews led by a theme-based interview guide.

Objectives

To generate new knowledge regarding user experiences of standing and walking with Ekso™ (Ekso Bionics, Richmond, CA, USA).

Setting

In-patient rehabilitation hospital in Norway.

Methods

Systematic inductive content analyses were used, utilizing a pattern theory of self as an analytical framework.

Results

The participants shared powerful stories, describing largely positive but also challenging emotions and perceptions, related to standing and walking with Ekso™. Four themes emerged: (1) bodily positions, possibilities and feelings, (2) reactivation of loss and hope for the future, (3) to be free and restricted at the same time, and (4) to be controlled and take control. The results indicate that both walking and using a wheelchair involve more than getting from one place to another, as fundamental aspects of being human are touched, involving facilitating a coherent understanding of the self and, on the other hand, leading to an "objectification" of the body.

Conclusions

This explorative study points toward contrasts involved when using Ekso™. More studies of lived experiences with walking in Ekso™ are needed, comprising larger samples, variations in participant characteristics and diagnoses as well as contexts.

Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers

BACKGROUND AND PURPOSE

Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility.

METHODS

We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions.

RESULTS

Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support.

DISCUSSION AND CONCLUSIONS

Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A231).

Perspectives of people with spinal cord injury learning to walk using a powered exoskeleton

BACKGROUND

Powered exoskeletons for over ground walking were designed to help people with neurological impairments to walk again. Extended training in powered exoskeletons has led to changes in walking and physiological functions. Few studies have considered the perspective of the participants. The users' perspective is vital for adoption of assistive devices. We explored the expectations and experiences of persons with spinal cord injury, training with the ReWalk exoskeleton.

METHODS

A qualitative research design with individual interviews was used. Eleven participants with spinal cord injury, taking part in 12 weeks of 4 times weekly training using the ReWalk, were interviewed before, immediately after, and 2 months after training. Interviews were audio recorded and transcribed verbatim. A six stage approach to thematic analysis was used.

RESULTS

The theme consistently expressed was the exoskeleton allowed participants to do everyday activities, like everyone else, such as looking people in the eye or walking outside. Their experiences were captured in three categories: 1) learning, a description of both expectations for learning and perspectives on how learning occurred; 2) changing, perspectives on perceived changes with training; and 3) contributing, which captured participant perspectives on contributing to research, including the giving of direct feedback regarding the exoskeleton (i.e., what worked and what could be changed).

CONCLUSIONS

Incorporating the view of the user in the design and refinement of exoskeletons will help ensure that the devices are appropriate for future users. Availability and support for the use of exoskeleton devices in community settings is an interim step to home use as the devices continue to improve.

TRIAL REGISTRATION

www.clinicaltrials.gov ( NCT02322125 ). Registered Dec 22, 2014 - Retrospectively registered after the first 4 participants had enrolled in the study.

What Do Older Adults and Clinicians Think About Traditional Mobility Aids and Exoskeleton Technology?

Mobility impairments can prevent older adults from performing their daily activities, which highly impacts quality of life. Powered exoskeletons, which are wearable robotic devices, can assist older adults by providing additional support to compensate for age-related decline in muscle strength. To date, little is known about the opinions and needs of older adults regarding exoskeletons, as current research primarily focuses on the technical development of exoskeleton devices and on groups with more severe mobility impairments such as people with spinal cord injuries. Therefore, the aim of this article is to inform the design of exoskeletons for older adults from a person-centered perspective. Interviews were conducted with seven older adults and six clinicians. Results indicated that exoskeletons can be a valuable addition to existing mobility devices to support older adults during walking and other actions necessary to perform their daily activities. Although reactions towards the concept of exoskeleton technology were positive, older adults did not currently perceive the need for an exoskeleton device. Exoskeletons for older adults should be easy to use; preferably, users should be able to put the device on and take it off independently. Moreover, the appearance of the exoskeleton should be as inconspicuous as possible, as most older adults do not like to advertise their need for assistive devices. At this point in time, the willingness to use exoskeleton technology will depend on personal needs and preferences.

Bydgostian hand exoskeleton – own concept and the biomedical factors

An exoskeleton is defined as a distinctive kind of robot to be worn as an overall or frame, effectively supporting, or in some cases substituting for, the user’s own movements. In this paper a new three-dimensional (3D) printed bydgostian hand exoskeleton is introduced and biomedically characterized. The proposed concept is promising, and the described approach combining biomechanical factors and 3D modeling driven by detailed hand exoskeleton patterns may constitute a key future method of ergonomic hand exoskeleton design and validation prior to manufacturing. Despite the aforementioned approach, we should be aware that hand exoskeleton constitutes hand support and rehabilitation robot system developing with the user; thus, certain coordination and continuity of the “hardware” part of the whole system and the training paradigm are essential for therapy efficacy.

Systematic Reviews of Clinical Benefits of Exoskeleton Use for Gait and Mobility in Neurologic Disorders: A Tertiary Study

OBJECTIVE

To describe systematic reviews (SRs) of the use of exoskeletons for gait and mobility by persons with neurologic disorders and to evaluate their quality as guidance for research and clinical practice.

DATA SOURCES

PubMed, EMBASE, Web of Science, CINAHL Complete, PsycINFO, Cochrane Database of Systematic Reviews, PEDro, and Google Scholar were searched from database inception to January 23, 2018.

STUDY SELECTION

A total of 331 deduplicated abstracts from bibliographic database and ancestor searching were independently screened by 2 reviewers, resulting in 109 articles for which full text was obtained. Independent screening of those 109 articles by 2 reviewers resulted in a final selection of 17 SRs.

DATA EXTRACTION

Data were extracted by 1 reviewer using a pretested Excel form with 158 fields and checked by a second reviewer. Key data included the purpose of the SR, methods used, outcome measures presented, and conclusions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and A MeaSurement Tool to Assess Systematic Reviews version 2 were used to evaluate reporting and methodological quality, respectively, of the SRs.

DATA SYNTHESIS

The SRs generally were of poor methodological and reporting quality. They failed to report some information on patients (eg, height, weight, baseline ambulatory status) and interventions (eg, treatment hours or sessions planned and delivered) that clinicians and other stakeholders might want to have, and often failed to notice that the primary studies duplicated subjects.

CONCLUSIONS

Published SRs on exoskeletons have many weaknesses in design and execution; clinicians, researchers, and other stakeholders should be cautious in relying on them to make decisions on the use of this technology. Future primary and secondary studies need to address the multiple methodological limitations.

Arquitectura de un sistema de medición de bioparámetros integrando señales inerciales-magnéticas y electromiográficas

Este trabajo presenta una arquitectura para la medición e integración de bioparámetros basado en unidades de procesamiento de movimiento inercial-magnético (MPUs) y electromiografía (EMG). Derivado de la arquitectura propuesta, se logró desarrollar un dispositivo llamado Imocap, el cual reúne y utiliza las mejores características de la tecnología MPU + EMG para realizar una medición completa en el segmento de brazo y antebrazo en el cuerpo humano. Se presenta en primer lugar la revisión bibliográfica de los métodos y herramientas para la captura del movimiento biomecánico, seguido de las técnicas y aplicaciones de la recolección de bioparámetros. Finalmente, se muestra la arquitectura y la descripción del sistema Imocap, algunas aplicaciones y discusión. Como trabajo futuro, Imocap tiene como objetivo proporcionar la información necesaria en un sistema de control electrónico para una plataforma de rehabilitación basada en exoesqueletos robóticos.