A survey of stakeholder perspectives on exoskeleton technology

Barriers and facilitators to exoskeleton use in persons with spinal cord injury: a systematic review

PURPOSE

Exoskeleton can assist individuals with spinal cord injuries (SCI) with simple movements and transform their lives by enhancing strength and mobility. Nonetheless, the current utilization outside of rehabilitation contexts is limited. To promote the widespread adoption of exoskeletons, it is crucial to consider the acceptance of these devices for both rehabilitation and functional purposes. This systematic review aims to identify the barriers or facilitators of the use of lower limbs exoskeletons, thereby providing strategies to improve interventions and increase the adoption of these devices.

METHODS

A comprehensive search was conducted in EMBASE, Web of Science, Scopus, Cochrane, and PubMed. Studies reporting barriers and facilitators of exoskeleton use were included. The studies' quality was assessed using the Mixed Methods Appraisal Tool and undertook a thematic content analysis for papers examining the barriers and facilitators.

RESULTS

Fifteen articles met the inclusion criteria. These revealed various factors that impact the utilization of exoskeletons. Factors like age, engagement in an active lifestyle, and motivation were identified as facilitators, while fear of falling and unfulfilled expectations were recognized as barriers. Physical aspects such as fatigue, neuropathic discomfort, and specific health conditions were found to be barriers.

CONCLUSION

This systematic review provides a comprehensive overview of the barriers and facilitators to the use of exoskeleton technology. There are therefore still challenges to be faced, efforts must be made to improve its design, functionality, and accessibility. By addressing these barriers, exoskeletons can significantly improve the quality of life of people with SCI.

Corporate social responsibility: A key driver of sustainable development in China's post-COVID economy

The first goal of this research was to measure the impact of corporate social responsibility (CSR) on the sustainable development of an organization. However, the second objective examines the moderating influence of government policies, cultural norms, and stakeholder expectations on the relationship between CSR and an organization's sustainable development. This research primarily focused on the enterprises operating in the energy industry in Beijing. A sample of 498 individuals holding management positions within these enterprises was collected. The study's results established that CSR significantly influences the sustainable development of firms. Moreover, the results revealed that governmental regulations, cultural norms, and stakeholder expectations play a significant and positive role in moderating the impact of corporate social responsibility on the sustainable development of companies. The results of this study make a valuable contribution to the existing body of literature on CSR and its impact on the sustainable performance of enterprises in China.

Human-centered design of a novel soft exosuit for post-stroke gait rehabilitation

BACKGROUND

Stroke remains a major cause of long-term adult disability in the United States, necessitating the need for effective rehabilitation strategies for post-stroke gait impairments. Despite advancements in post-stroke care, existing rehabilitation often falls short, prompting the development of devices like robots and exoskeletons. However, these technologies often lack crucial input from end-users, such as clinicians, patients, and caregivers, hindering their clinical utility. Employing a human-centered design approach can enhance the design process and address user-specific needs.

OBJECTIVE

To establish a proof-of-concept of the human-centered design approach by refining the NewGait® exosuit device for post-stroke gait rehabilitation.

METHODS

Using iterative design sprints, the research focused on understanding the perspectives of clinicians, stroke survivors, and caregivers. Two design sprints were conducted, including empathy interviews at the beginning of the design sprint to integrate end-users' insights. After each design sprint, the NewGait device underwent refinements based on emerging issues and recommendations. The final prototype underwent mechanical testing for durability, biomechanical simulation testing for clinical feasibility, and a system usability evaluation, where the new stroke-specific NewGait device was compared with the original NewGait device and a commercial product, Theratogs®.

RESULTS

Affinity mapping from the design sprints identified crucial categories for stakeholder adoption, including fit for females, ease of donning and doffing, and usability during barefoot walking. To address these issues, a system redesign was implemented within weeks, incorporating features like a loop-backed neoprene, a novel closure mechanism for the shoulder harness, and a hook-and-loop design for the waist belt. Additional improvements included reconstructing anchors with rigid hook materials and replacing latex elastic bands with non-latex silicone-based bands for enhanced durability. Further, changes to the dorsiflexion anchor were made to allow for barefoot walking. Mechanical testing revealed a remarkable 10-fold increase in durability, enduring 500,000 cycles without notable degradation. Biomechanical simulation established the modularity of the NewGait device and indicated that it could be configured to assist or resist different muscles during walking. Usability testing indicated superior performance of the stroke-specific NewGait device, scoring 84.3 on the system usability scale compared to 62.7 for the original NewGait device and 46.9 for Theratogs.

CONCLUSION

This study successfully establishes the proof-of-concept for a human-centered design approach using design sprints to rapidly develop a stroke-specific gait rehabilitation system. Future research should focus on evaluating the clinical efficacy and effectiveness of the NewGait device for post-stroke rehabilitation.

Clinical Uptake of Pediatric Exoskeletons: Pilot Study Using the Consolidated Framework for Implementation Research

OBJECTIVE

While the design and clinical evidence base of robot-assisted gait training devices has been advancing, few studies investigate user experiences with accessing and using such devices in pediatric rehabilitation. This pilot study aims to further the understanding of barriers encountered by clinicians and caregivers when implementing a robot-assisted gait training device.

DESIGN

A qualitative descriptive study was conducted at a local outpatient pediatric therapy center with a robot-assisted gait training exoskeleton. Six caregivers and six clinicians participated in semistructured interviews with brief surveys. The surveys were summarized with descriptive statistics. The interviews were analyzed using directed content analysis guided by the Consolidated Framework for Implementation Research.

RESULTS

The five most mentioned Consolidated Framework for Implementation Research constructs were knowledge and beliefs, relative advantage, child attributes, complexity, and access to knowledge and information. Caregivers experienced obstacles to accessing and trialing robot-assisted gait training devices. Clinicians expressed concerns regarding the feasibility of incorporating robot-assisted gait training into their clinic and preferred lower-tech gait training techniques.

CONCLUSIONS

While some aspects of access and usability may be addressed by device design and technological advancements, overcoming other barriers will require a deeper understanding of the roles of scientific evidence, personal beliefs, and current therapy workflows in the uptake of robotic interventions.

Multidisciplinary collaboration on exoskeleton development adopting user-centered design: a systematic integrative review

Purpose: The world population is ageing, along with an increasing possibility of functional limitations that affect independent living. Assistive technologies such as exoskeletons for rehabilitative purposes and daily activities assistance maintaining the independence of people with disabilities, especially older adults who wish to ageing-in-place. The purpose of this systematic integrative review was threefold: to explore the development team compositions and involvement, to understand the recruitment and engagement of stakeholders, and to synthesise reported or anticipated consequences of multidisciplinary collaboration.Methods: Databases searched included PubMed, CINAHL Plus, PsycINFO, Web of Science, Scopus, and IEEE Xplore. A total of 34 studies that reported the development of exoskeleton adopting user-centered design (UCD) method in healthcare or community settings that were published in English from 2000 to July 2022 were included.Results: Three major trends emerged from the analysis of included studies. First, there is a need to redefine multidisciplinary collaboration, from within-discipline collaboration to cross-discipline collaboration. Second, the level of engagement of stakeholders during the exoskeleton development remained low. Third, there was no standardised measurement to quantify knowledge production currently.Conclusion: As suggested by the synthesised results in this review, exoskeleton development has been increasing to improve the functioning of people with disabilities. Exoskeleton development often required expertise from different disciplines and the involvement of stakeholders to increase acceptance, thus we propose the Multidisciplinary Collaboration Appraisal Tool to assess multidisciplinary collaboration using the UCD approach. Future research is required to understand the effectiveness of multidisciplinary collaboration on exoskeleton development using the UCD approach.IMPLICATIONS FOR REHABILITATIONGlobal trend of population ageing causes a higher risk of disability in older adults who require rehabilitation and assistance in daily living.Assistive technologies such as exoskeletons have the potential to contribute to rehabilitation training and daily activity assistance demand closer multidisciplinary collaboration.A Multidisciplinary Collaboration Appraisal Tool using user-centered design approach (MCAT) is proposed to understand the effectiveness as well as limitations and barriers associated with multidisciplinary collaboration in developing exoskeletons.

"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.

Design and Control of a Soft Knee Exoskeleton for Pediatric Patients at Early Stages of the Walking Learning Process

Pediatric patients can suffer from different motor disorders that limit their neurological and motor development and hinder their independence. If treated at the very early stages of development, those limitations can be palliated or even removed. However, manual interventions are not completely effective due to the restrictions in terms of time, force, or tracking experienced by the physiotherapists. The knee flexo-extension is crucial for walking and often affected by disorders such as spasticity or lack of force in the posterior chain. This article focuses on the development of a knee exosuit to follow angular trajectories mimicking the maximum and minimum peaks present in the knee flexo-extension profiles of healthy individuals during walking. The proposed exosuit is based on shape memory alloy actuators along with four inertial sensors that close the control loop. The whole device is controlled through a two-level controller and has an hybrid rigid-flexible design to overcome the different issues present in the literature. The device was proven to be feasible for this type of application, with replicable and consistent behavior, reducing the price and weight of existing exosuits and enhancing patient comfort.

Validation of a modified visual analogue scale to measure user-perceived comfort of a lower-limb exoskeleton

User perceived exoskeleton comfort is likely important for device acceptance, but there is currently no validated instrument to measure it. The Visual Analogue Scale (VAS) is an existing tool to measure subjective human feedback by asking the user to mark a point on a line with each end of the line representing an opposing anchor statement. It can be modified to show the previous response, allowing the subject to directly indicate if the current condition is better or worse than the previous one. The goal of this study was to determine how well the modified VAS could measure user-perceived comfort as the exoskeleton control parameters were varied. To validate the survey, 14 healthy subjects walked in a pair of ankle exoskeletons with approximately ten distinct sets of control parameters tested in a prescribed order. Each set of control parameters was tested twice. After each trial, user-perceived comfort was measured using a two-question VAS survey. The repeatability coefficient was approximately 40 mm, similar to the total range of responses. The results were also inconsistent, with relative rankings between consecutive pairs of conditions matching for approximately 50% of comparisons. Thus, as tested, the VAS was not repeatable or consistent. It is possible that subject adaptation within the trial and over the course of the experiment may have impacted the results. Additional work is needed to develop a repeatable method to measure comfort and to determine how perceived comfort varies as subjects' gain exoskeleton experience.

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 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.

Manipulating device-to-body forces in passive exosuit: An experimental investigation on the effect of moment arm orientation using passive back-assist exosuit emulator

Passive exosuits have been vastly researched in the past decade for lifting tasks to alleviate the mechanical loading on the spine and reduce the lower back muscle activities in lifting tasks. Despite promising advantages of exosuits, factors such as comfort directly influence the user's acceptability of such body-worn devices. Exosuits' routing/anchoring points, which transmit device-to-body forces, remain the leading cause of discomfort among users. In the present study, we sought to investigate the effect of the routing element, that is, the "moment arm," in altering the device-to-body forces and perceived discomfort. We first presented a simplified human-exosuit model to establish insight into the effect of the moment arm on the device-to-body forces acting at the shoulder (FS) and waist (FW). Further, an experimental investigation was conducted on 10 participants with six different exosuit moment arm configurations (C1, C2, C3, C4, C5, and C6) to investigate their effect on the device-to-body forces, perceived discomfort, and muscle activity using a passive back-assist exosuit emulator in a lifting/lowering task. Configuration C4 was found to be most beneficial in reducing device-to-body forces at the shoulder and waist by up to 44.6 and 22.2%, respectively, during lifting. Subjective scores also comprehended with the device-to-body forces, indicating that C4 produces significantly less discomfort for participants. The outcome of the study illustrates the importance of selecting an appropriate moment arm configuration for passive back support exosuits in alleviating the device-to-body forces and perceived discomfort.

Perspectives on ankle-foot technology for improving gait performance of children with Cerebral Palsy in daily-life: requirements, needs and wishes

BACKGROUND

Ankle-foot orthoses (AFOs) are extensively used as a primary management method to assist ambulation of children with Cerebral Palsy (CP). However, there are certain barriers that hinder their prescription as well as their use as a mobility device in all kinds of daily-life activities. This exploratory research attempts to further understand the existing limitations of current AFOs to promote a better personalization of new design solutions.

METHODS

Stakeholders' (professionals in CP and end-users with CP) perspectives on AFO technology were collected by two online surveys. Respondents evaluated the limitations of current assistive solutions and assessment methods, provided their expectations for a new AFO design, and analyzed the importance of different design features and metrics to enrich the gait performance of these patients in daily-life. Quantitative responses were rated and compared with respect to their perceived importance. Qualitative responses were classified into themes by using content analysis.

RESULTS

130 survey responses from ten countries were analyzed, 94 from professionals and 36 from end-users with CP. The most highly rated design features by both stakeholder groups were the comfort and the ease of putting on and taking off the assistive device. In general, professionals preferred new features to enrich the independence of the patient by improving gait at functional levels. End-users also considered their social acceptance and participation. Health care professionals reported a lack of confidence concerning decision-making about AFO prescription. To some degree, this may be due to the reported inconsistent understanding of the type of assistance required for each pathological gait. Thus, they indicated that more information about patients' day-to-day walking performance would be beneficial to assess patients' capabilities.

CONCLUSION

This study emphasizes the importance of developing new approaches to assess and treat CP gait in daily-life situations. The stakeholders' needs and criteria reported here may serve as insights for the design of future assistive devices and for the follow-up monitoring of these patients.

Needs and wishes for the future lower limb exoskeleton: an interview study among people with spinal cord injury with community-based exoskeleton experience

PURPOSE

Exoskeleton use by people with complete spinal cord injury (SCI) in daily life is challenging. To optimize daily exoskeleton use, a better understanding of the purpose of use and the accompanying improvements are needed. The perspective of experienced exoskeleton users could guide design improvements.

METHODS

Face-to-face semi-structured interviews were held with 13 people with SCI with exoskeleton experience. Interviews were audio-taped, transcribed, and analysed thematically.

RESULTS

Participants expressed three future purposes of exoskeleton use: for daily activities (e.g., stair climbing), exercise (e.g., staying healthy), and social interaction (e.g., standing at parties). Exoskeleton use during daily activities was the ultimate goal. Therefore, the future exoskeleton should be: easy to use, small and lightweight, tailor made, safe, comfortable, less distinctive, durable, and affordable. Improving the ease of use was relevant for all purposes, for all participants. The other suggestions for improvement varied depending on the purpose of use and the participant.

CONCLUSION

Increasingly more advanced improvements are needed to transition from an exercise purpose to social interaction, and ultimately use during daily activities. In the current study, detailed suggestions for improvements have been made. Only when multiple of these suggestions are adjusted, can the exoskeleton be used to its full potential.IMPLICATIONS FOR REHABILITATIONThe use of an exoskeleton by people with a complete spinal cord injury in daily life is still in its infancy.To optimize daily exoskeleton use, a better understanding of the purpose of use and exoskeleton improvements is needed.More advanced improvements to future exoskeletons are needed to make a transition from use as an exercise device to use during social interaction and daily activities.Improving the ease of use of future exoskeletons is considered a priority by experienced users, followed by making the exoskeleton small, lightweight, and tailor made.

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.

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.

A Systematic Review of Low-Cost Actuator Implementations for Lower-Limb Exoskeletons: a Technical and Financial Perspective

A common issue with many commercial rehabilitative exoskeletons and orthoses are that they can be prohibitively expensive for an average individual to afford without additional financial support. Due to this a user may have limited to the usage of such devices within set rehabilitation sessions as opposed to a continual usage. The purpose of this review is therefore to find which actuator implementations would be most suitable for a simplistic, low-cost powered orthoses capable of assisting those with pathologic gait disorders by collating literature from Web of Science, Scopus, and Grey Literature. In this systematic review paper 127 papers were selected from these databases via the PRISMA guidelines, with the financial costs of 25 actuators discovered with 11 distinct actuator groups identified. The review paper will consider a variety of actuator implementations used in existing lower-limb exoskeletons that are specifically designed for the purpose of rehabilitating or aiding those with conditions inhibiting natural movement abilities, such as electric motors, hydraulics, pneumatics, cable-driven actuators, and compliant actuators. Key attributes such as technical simplicity, financial cost, power efficiency, size limitations, accuracy, and reliability are compared for all actuator groups. Statistical findings show that rotary electric motors (which are the most common actuator type within collated literature) and compliant actuators (such as elastic and springs) would be the most suitable actuators for a low-cost implementation. From these results, a possible actuator design will be proposed making use of both rotary electric motors and compliant actuators.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10846-022-01695-0.

Knowledge Gaps in Biophysical Changes After Powered Robotic Exoskeleton Walking by Individuals With Spinal Cord Injury—A Scoping Review

In addition to helping individuals with spinal cord injury (SCI) regain the ability to ambulate, the rapidly evolving capabilities of robotic exoskeletons provide an array of secondary biophysical benefits which can reduce the complications resulting from prolonged immobilization. The proposed benefits of increased life-long over-ground walking capacity include improved upper body muscular fitness, improved circulatory response, improved bowel movement regularity, and reduced pain and spasticity. Beyond the positive changes related to physical and biological function, exoskeletons have been suggested to improve SCI individuals' quality of life (QOL) by allowing increased participation in day-to-day activities. Most of the currently available studies that have reported on the impact of exoskeletons on the QOL and prevention of secondary health complications on individuals with SCI, are of small scale and are heterogeneous in nature. Moreover, few meta-analyses and reviews have attempted to consolidate the dispersed data to reach more definitive conclusions of the effects of exoskeleton use. This scoping review seeks to provide an overview on the known effects of overground exoskeleton use, on the prevention of secondary health complications, changes to the QOL, and their effect on the independence of SCI individuals in the community settings. Moreover, the intent of the review is to identify gaps in the literature currently available, and to make recommendations on focus study areas and methods for future investigations.

Reference theories and future perspectives on robot-assisted rehabilitation in people with neurological conditions: A scoping review and recommendations from the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE)

BACKGROUND

Robot-based treatments are developing in neurorehabilitation settings. Recently, the Italian National Health Systems recognized robot-based rehabilitation as a refundable service. Thus, the Italian neurorehabilitation community promoted a national consensus on this topic.

OBJECTIVE

To conceptualize undisclosed perspectives for research and applications of robotics for neurorehabilitation, based on a qualitative synthesis of reference theoretical models.

METHODS

A scoping review was carried out based on a specific question from the consensus Jury. A foreground search strategy was developed on theoretical models (context) of robot-based rehabilitation (exposure), in neurological patients (population). PubMed and EMBASE® databases were searched and studies on theoretical models of motor control, neurobiology of recovery, human-robot interaction and economic sustainability were included, while experimental studies not aimed to investigate theoretical frameworks, or considering prosthetics, were excluded.

RESULTS

Overall, 3699 records were screened and finally 9 papers included according to inclusion and exclusion criteria. According to the population investigated, structured information on theoretical models and indications for future research was summarized in a synoptic table.

CONCLUSION

The main indication from the Italian consensus on robotics in neurorehabilitation is the priority to design research studies aimed to investigate the role of robotic and electromechanical devices in promoting neuroplasticity.

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.

Physiotherapy using a free-standing robotic exoskeleton for patients with spinal cord injury: a feasibility study

BACKGROUND

Evidence is emerging for the use of overground lower limb robotic exoskeletons in the rehabilitation of people with spinal cord injury (SCI), with suggested benefits for gait speed, bladder and bowel function, pain management and spasticity. To date, research has focused on devices that require the user to support themselves with a walking aid. This often precludes use by those with severe trunk, postural or upper limb deficits and places the user in a suboptimal, flexed standing position. Free-standing exoskeletons enable people with higher level injuries to exercise in an upright position. This study aimed to evaluate the feasibility of therapy with a free-standing exoskeleton for those with SCI, and to determine the potential health-related benefits of this intervention.

METHODS

This 12-week intervention study with 12-week waitlist control and 12-week follow up, provided people with SCI scoring < 5 on the mobility section of the spinal cord independence measure (SCIM-III) twice weekly therapy in the REX (Rex Bionics, Auckland, NZ), a free-standing lower limb robotic exoskeleton. The primary outcome measure of interest was function, as measured on the SCIM-III. A battery of secondary outcomes was included. Participants also completed a survey on their perceptions of this treatment modality, to determine acceptability.

RESULTS

Forty-one potential participants were screened for eligibility. Two females (one ASIA A, one ASIA C) and one male (ASIA B) completed all 24 intervention sessions, and the follow up assessment. One participant showed positive trends in function, fatigue, quality of life and mood during the intervention phase. Grip and quadriceps strength, and lower limb motor function improved in another. Two improved their percentage of lean body mass during the intervention phase. Remaining results were varied across patients, time points and outcomes. The intervention was highly acceptable to all participants.

CONCLUSION

With three of 41 potential participants being eligible and completing this study, our results show that there are potential benefits of exercise in a free-standing exoskeleton for people with severe mobility impairment due to SCI, for a small subset of patients. Further research is warranted to determine those most likely to benefit, and the type of benefit depending on the patient characteristics. Trial registration The trial was registered prospectively on 20 April 2018 at www.anzctr.org.au/ (ACTRN12618000626268).

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.

Static force and tipover stability analysis of an assistive device for paraplegics

Stability plays a vital role in any robotic system. Its significance increases in systems related to health and medicine. For rehabilitation devices meant for Spinal Cord Injury (SCI) patients, stability is crucial and key element in ensuring patient safety and the usefulness of the devices. In this study, kinematics, force analysis, and the static tip-over stability of a device for rehabilitation of paraplegic patients is discussed. Kinematics modeling and static force analysis provide critical information about position and loading at different points on the device. Force-Angle Stability Criterion is used to find the static tip-over stability of the device while the patient is on board the device. The Criterion relies on the support boundary, tip-over mode axes, and the Center of Mass (COM) of the complete system. The Criterion is sensitive to the COM position and therefore is more suitable for the application. The linear actuator mounted on the device causes the end effector of the device to move. The patient, strapped with the end effector, in turn moves from sitting position to standing position. The study focuses on the analysis of stability based on changing COM during this motion. The results verify that although the system is well within the stability bounds, it is more stable as it moves from sitting position to standing position.

Design, modeling, and demonstration of a new dual-mode back-assist exosuit with extension mechanism

Occupational exoskeletons and exosuits have been shown to reduce muscle demands and fatigue for physical tasks relevant to a variety of industries (e.g. logistics, construction, manufacturing, military, healthcare). However, adoption of these devices into the workforce has been slowed by practical factors related to comfort, form-factor, weight, and not interfering with movement or posture. We previously introduced an un-motorized, low-profile, dual-mode exosuit comprised of textile and elastic materials to address these adoption barriers. Here we build upon this prior work by introducing an extension mechanism that increases the moment arm of the exosuit while in engaged mode, then collapses in disengaged mode to retain key benefits related to being lightweight, low-profile, and unobstructive. Here we demonstrate both analytically and empirically how this extensible exosuit concept can (i) reduce device-to-body forces (which can improve comfort for some users and situations), or (ii) increase the magnitude of torque assistance about the low back (which may be valuable for heavy-lifting jobs) without increasing shoulder or leg forces relative to the prior form-fitting exosuit. We also introduce a novel mode-switching mechanism, as well as a human-exosuit biomechanical model to elucidate how individual design parameters affect exosuit assistance torque and device-to-body forces. The proof-of-concept prototype, case study, and modeling work provide a foundation for understanding and implementing extensible exosuits for a broad range of applications. We envision promising opportunities to apply this new dual-mode extensible exosuit concept to assist heavy-lifting, to further enhance user comfort, and to address the unique needs of last-mile delivery workers.

Wearable Exoskeletons on the Workplaces: Knowledge, Attitudes and Perspectives of Health and Safety Managers on the implementation of exoskeleton technology in Northern Italy

BACKGROUND

Exoskeleton technology (ExT) has potential to significantly improve occupational health and safety. However, studies on stakeholders' perspectives are lacking. To facilitate the implementation of ExT on the workplaces, a study was undertaken exploring specific knowledge, attitudes and perspectives (KAP) of Health and Safety Consultants (HSC).

METHODS

An online survey with quantitative and qualitative components was conducted with HSC participating to a series of qualification courses focusing on new technologies in occupational settings. Respondents rated whether they would use or recommend an exoskeleton, being assessed regarding their knowledge on ExT through a specifically designed knowledge test. Design features (n = 16) and expected benefits (n = 12) were rated and compared in terms of their importance. Regression analysis was used to identify factors significantly affecting the propensity towards the implementation of ExT.

RESULTS

A total of 59 HSC participated to the survey (participation rate, 90.8%): of them, 20 (33.9%) were somehow favorable towards the use of ExT on the workplaces. The most highly rated reason for potential use/recommendation of ExT was reducing the stress on joints and tendons (74.6%), followed by reducing muscle fatigue (71.2%). Among design features, higher ratings were identified for: comfort (4.53 ± 0.68), ease of setup (4.37 ± 0.72), portability (4.32 ± 0.97), minimization of falls risk (4.31 ± 0.93), ease of putting on/taking off the device (4.12 ± 1.16), and amount of physical energy needed for use (4.14 ± 0.92). Overall knowledge of ExT was quite low (knowledge score 43.2% ± 18.2), with high rate of false beliefs on the protective role of ExT on musculoskeletal disorders and physical efforts, positive effects on productivity. In multivariate analysis, age < 50 years and being an internal HSC were identified as significant effectors for a positive attitude towards ExT.

CONCLUSIONS

This study emphasizes the opportunity to spread better knowledge of actual ExT features among potential stakeholders. Moreover, design of future exoskeleton should focus on devices comfortable, highly portable, ease to setup, with a reduced risk of falls.

Technology acceptance and perceptions of robotic assistive devices by older adults - implications for exoskeleton design

AIM

This study explored and interpreted insights expressed by a cohort of older adults related to their life experience, their experiences using or assisting someone with assistive devices, and their perceptions of robots and robotic assistive devices, including lower limb exoskeletons.

METHOD

A grounded theory study was undertaken with 24 older adult participants over five months. Each participant participated in a structured interviewed regarding their experiences with technologies and in particular their perceptions of assistive technologies. Themes from the interviews were coded using Nvivo software.

RESULTS

Five main themes emerged from this study - (1) Aging & life stage experiences, (2) Quality of Life, (3) Assistive Technologies, (4) Health Conditions & Care, (5) Products & Service Systems. These have influenced new constructs for a hybrid design tool that incorporates stages of Usability and TAMs (Technology Acceptance Models) to gauge (a) Perception, (b) Experience and (c) Perceived Impact by older adults of lower limb exoskeletons.

Conclusions: Emerging technologies such as robotic assistive devices require a specific enquiry to understand how best to optimise acceptance by older adults and avoid feelings by them of frustration, embarrassment and ultimately abandonment of these devices.Implications for rehabilitationOlder adults frequently require rehabilitation and assistance with ambulationExoskeletons are forms of assistive technologies for rehabilitation, and they are moving from clinical use to more day care use, including as part of daily livingThese results help explain factors related to the perception of exoskeletons by older adults, which if considered during exoskeleton design, could improve the technology uptake and compliance with this technology use by these users.

"It's All Sort of Cool and Interesting…but What Do I Do With It?" A Qualitative Study of Stroke Survivors' Perceptions of Surface Electromyography

Background: Stroke is one of the most common neurologic injuries worldwide. Over decades, evidence-based neurorehabilitation research and advancements in wireless, wearable sensor design have supported the deployment of technologies to facilitate recovery after stroke. Surface electromyography (sEMG) is one such technology, however, clinical application remains limited. To understand this translational practice gap and improve clinical uptake, it is essential to include stakeholder voices in an analysis of neurorehabilitation practice, the acceptability of current sEMG technologies, and facilitators and barriers to sEMG use in the clinic and the community. The purpose of this study was to foreground the perspectives of stroke survivors to gain a better understanding of their experiences in neurorehabilitation, the technologies they have used during their recovery, and their opinions of lab-designed and commercially-available sEMG systems. Methods: A qualitative, phenomenological study was completed. In-depth, semi-structured interviews were conducted with eight stroke survivors (age range 49-78 years, 6 months to 12 years post-stroke) and two caregivers from a large metropolitan region. A demonstration of four sEMG systems was provided to gather perceptions of sensor design, features and function, and user interface. Interviews were audio-recorded, transcribed verbatim, and coded for analysis using constant comparison until data saturation was reached. Results: Three themes emerged from the data: (1) "Surface EMG has potential….but…" highlights the recognition of sEMG as a valuable tool but reveals a lack of understanding and need for clear meaning from the data; (2) "Tracking incremental progress over days or years is important" highlights the persistence of hope and potential benefit of sEMG in detecting small changes that may inform neurorehabilitation practice and policy; and (3) "Neurorehabilitation technology is cumbersome" highlights the tension between optimizing therapy time and trying new technologies, managing cost, logistics and set-up, and desired technology features. Conclusion: Further translation of sEMG technology for neurorehabilitation holds promise for stroke survivors, but sEMG system design and user interface needs refinement. The process of using sEMG technology and products must be simple and provide meaningful insight to recovery. Including stroke survivors directly in translational efforts is essential to improve uptake in clinical environments.

Physiotherapy students' perspectives on the use and implementation of exoskeletons as a rehabilitative technology in clinical settings

PURPOSE

Wearable lower body robotic exoskeletons are an emerging technology used in gait rehabilitation to facilitate task-specific overground walking. Despite their proposed utility as a rehabilitation intervention, exoskeletons have not been widely implemented into clinical practice by physiotherapists. This study aims to inform future development of exoskeleton technology through the exploration of physiotherapy student perspectives on the use of the H2 robotic exoskeleton and the implementation of exoskeletons as a therapeutic technology in neurological gait rehabilitation.

METHODS

A qualitative descriptive study, including fifteen physiotherapy students, was conducted using three equally sized focus groups. A collaborative data analysis process was employed using the DEPICT model.

RESULTS

Five themes were identified during data analysis: developing evidence-informed practice, clinical considerations for exoskeleton use, resource demands, device-specific challenges for implementation, and future development. The results suggest there are several barriers limiting novel clinicians' future use of exoskeletons.

CONCLUSION

This study highlights current challenges surrounding exoskeleton implementation into clinical practice and provides direction for future exoskeleton development.Implications for rehabilitationPhysiotherapy students view exoskeletons as a potentially valuable rehabilitation tool once perceived limitations are addressed.This study encourages collaboration between physiotherapists and biomedical engineers for future exoskeleton development.More research is needed to inform treatment parameters and appropriate client criteria to guide exoskeleton use for gait rehabilitation.

Users with spinal cord injury experience of robotic Locomotor exoskeletons: a qualitative study of the benefits, limitations, and recommendations

Background

Persons with spinal cord injury (SCI) may experience both psychological and physiological benefits from robotic locomotor exoskeleton use, and knowledgeable users may have valuable perspectives to inform future development. The objective of this study is to gain insight into the experiences, perspectives, concerns, and suggestions on the use of robotic locomotor exoskeletons by civilians and veterans living with SCI.

Methods

Participants reported their demographic characteristics and the extent of robotic exoskeleton use in an online survey. Then, 28 experienced robotic locomotor exoskeleton users participated in focus groups held at three regional hospitals that specialize in rehabilitation for persons with SCI. We used a qualitative description approach analysis to analyze the data, and included thematic analysis.

Results

Participants expressed that robotic exoskeletons were useful in therapy settings but, in their current form, were not practical for activities of daily living due to device limitations. Participants detailed the psychological benefits of being eye-level with their non-disabled peers and family members, and some reported physiologic improvements in areas such as bowel and bladder function. Participants detailed barriers of increased fatigue, spasticity, and spasms and expressed dissatisfaction with the devices due to an inability to use them independently and safely. Participants provided suggestions to manufacturers for technology improvements.

Conclusions

The varied opinions and insights of robotic locomotor exoskeletons users with SCI add to our knowledge of device benefits and limitations.

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.

Quasi-Direct Drive Actuation for a Lightweight Hip Exoskeleton with High Backdrivability and High Bandwidth

High-performance actuators are crucial to enable mechanical versatility of wearable robots, which are required to be lightweight, highly backdrivable, and with high bandwidth. State-of-the-art actuators, e.g., series elastic actuators (SEAs), have to compromise bandwidth to improve compliance (i.e., backdrivability). We describe the design and human-robot interaction modeling of a portable hip exoskeleton based on our custom quasi-direct drive (QDD) actuation (i.e., a high torque density motor with low ratio gear). We also present a model-based performance benchmark comparison of representative actuators in terms of torque capability, control bandwidth, backdrivability, and force tracking accuracy. This paper aims to corroborate the underlying philosophy of "design for control", namely meticulous robot design can simplify control algorithms while ensuring high performance. Following this idea, we create a lightweight bilateral hip exoskeleton to reduce joint loadings during normal activities, including walking and squatting. Experiments indicate that the exoskeleton is able to produce high nominal torque (17.5 Nm), high backdrivability (0.4 Nm backdrive torque), high bandwidth (62.4 Hz), and high control accuracy (1.09 Nm root mean square tracking error, 5.4% of the desired peak torque). Its controller is versatile to assist walking at different speeds and squatting. This work demonstrates performance improvement compared with state-of-the-art exoskeletons.

Appraisals of robotic locomotor exoskeletons for gait: focus group insights from potential users with spinal cord injuries

Purpose: To describe appraisals of robotic exoskeletons for locomotion by potential users with spinal cord injuries, their perceptions of device benefits and limitations, and recommendations for manufacturers and therapists regarding device use.Materials and methods: We conducted focus groups at three regional rehabilitation hospitals and used thematic analysis to define themes.Results: Across four focus groups, 35 adults participated; they were predominantly middle-aged, male, and diverse in terms of race and ethnicity, well educated, and not working. Participants had been living with SCI an average of two decades. Most participants were aware of exoskeletons. Some were enthusiastic about the usability of the devices while others were more circumspect. They had many questions about device affordability and usability, and were discerning in their appraisal of benefits and suitability to their particular circumstances. They reflected on device cost, the need for caregiver assistance, use of hands, and environmental considerations. They weighed the functional benefits relative to the cost of preferred activities. Their recommendations focused on cost, battery life, and independent use.Conclusions: Potential users' appraisals of mobility technology reflect a nuanced appreciation of device costs; functional, social, and psychological benefits; and limitations. Results provide guidance to therapists and manufacturers regarding device use.Implications for RehabilitationPotential users of robotic locomotor exoskeletons with spinal cord injuries appreciate the functional, social, and psychological benefits that these devices may offer.Their appraisals reflect nuanced consideration of device cost and features, and the suitability of the assistive technology to their circumstances.They recommend that manufacturers focus on reducing cost, extending battery life, and features that allow independent use.

User-centred assistive technology assessment of a portable open-area body weight support system for in-home use

PURPOSE

Current paediatric technology lacks mobility devices that support early, high-dose and variable movement that can be managed by professionals and parents outside of the lab or clinic. Parent acceptability of the technology is a critical piece to the continued use of devices by their infants. The purpose of this study was to determine the level of feasibility of an in-home application of a novel portable body weight support system (PBWSS), designed for community use.

METHOD

Sixteen typically and atypically developing infants used the system for four sessions at the home and lab. Parents assisted with the in-home system setup and completed a questionnaire on their: (a) infant's behavioural change, (b) infant's enjoyment, (c) own satisfaction, need and predicted use of the device, and (d) recommendations for future modifications.

RESULTS

Parents and their infants successfully used the device during a wide range of activities. Parents noted positive changes in their infants' behaviour including their infants initiating certain behaviours for the first time. Parents quickly learned to setup and use the device and were satisfied with its current structure. Future modifications included increasing the wearable harness comfort.

CONCLUSION

Infant performance and parent perceptions support the development of devices that place body-weight supported activity in real-world environments to promote high-dose, enriched experiences for young infants with mobility challenges.Implications for rehabilitationAssistive technology that can support multiple aspects of mobility in developing infants is limited.The in-home application of open-area body weight support systems has the potential to support early, enriched, high-dose mobility.Users of this technology, infants and their parents, were meaningfully involved throughout the assessment process.Preliminary findings support that: (1) this device was successfully implemented in these homes, (2) parents and infants enjoyed using the device, (3) parents noted positive changes in their infant's behavior, and (4) parents perceived the device to be safe and easy to use.Future studies can now determine the optimal use of this device with a range of pediatric populations.

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).

Unrecognized posterior dislocation of the humeral joint – a case report in the electronic decision-making system

The paper presents a description of a humeral joint dislocation case placed in full version in the electronic system of presenting content and making decisions. The purpose of the publication is to draw the attention of especially young, inexperienced adepts of medical art to the fact of making mistakes in the medical art. The process of dealing with the correct and incorrect procedures that occur while trying to identify a medical problem is discussed. The presented case gives the opportunity to have a broad view of the issue and is also faced with the need to make decisions by choosing the course of action, at every stage of analyzing the case. Mistakenly made decisions are explained. Finally, the correct diagnosis and medical procedure about the case of a humeral joint dislocation is presented.

Assisting gait with free moments or joint moments on the swing leg

Wearable actuators in lower-extremity active orthoses or prostheses have the potential to address a variety of gait disorders. However, whenever conventional joint actuators exert moments on specific limbs, they must simultaneously impose opposing reaction moments on other limbs, which may reduce the desired effects and perturb posture. Momentum exchange actuators exert free moments on individual limbs, potentially overcoming or mitigating these issues.We simulate unperturbed gait to compare conventional joint actuators placed on the knee or hip of the swing leg, and equivalent angular momentum exchange actuators placed on the shank or thigh. Our results indicate that, while conventional joint actuators excel at increasing toe clearance when assisting knee flexion, free moments can yield greater increases in stride length when assisting knee extension or hip flexion.

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.

A Soft+Rigid Hybrid Exoskeleton Concept in Scissors-Pendulum Mode: A Suit for Human State Sensing and an Exoskeleton for Assistance

In this paper, we present a novel concept that can enable the human aware control of exoskeletons through the integration of a soft suit and a robotic exoskeleton. Unlike the state-of-the-art exoskeleton controllers which mostly rely on lumped human-robot models, the proposed concept makes use of the independent state measurements concerning the human user and the robot. The ability to observe the human state independently is the key factor in this approach. In order to realize such a system from the hardware point of view, we propose a system integration frame that combines a soft suit for human state measurement and a rigid exoskeleton for human assistance. We identify the technological requirements that are necessary for the realization of such a system with a particular emphasis on soft suit integration. We also propose a template model, named scissor pendulum, that may encapsulate the dominant dynamics of the human-robot combined model to synthesize a controller for human state regulation. A series of simulation experiments were conducted to check the controller performance. As a result, satisfactory human state regulation was attained, adequately confirming that the proposed system could potentially improve exoskeleton-aided applications.

Design of a Low Profile, Unpowered Ankle Exoskeleton That Fits Under Clothes: Overcoming Practical Barriers to Widespread Societal Adoption

Here, we present the design of a novel unpowered ankle exoskeleton that is low profile, lightweight, quiet, and low cost to manufacture, intrinsically adapts to different walking speeds, and does not restrict non-sagittal joint motion; while still providing assistive ankle torque that can reduce demands on the biological calf musculature. This paper is an extension of the previously-successful ankle exoskeleton concept by Collins, Wiggin, and Sawicki. We created a device that blends the torque assistance of the prior exoskeleton with the form-factor benefits of clothing. Our design integrates a low profile under-the-foot clutch and a soft conformal shank interface, coupled by an ankle assistance spring that operates in parallel with the user's calf muscles. We fabricated and characterized technical performance of a prototype through benchtop testing and then validated device functionality in two gait analysis case studies. To our knowledge, this is the first ankle plantarflexion assistance exoskeleton that could be feasibly worn under typical daily clothing, without restricting ankle motion, and without components protruding substantially from the shoe, leg, waist, or back. Our new design highlights the potential for performance-enhancing exoskeletons that are inexpensive, unobtrusive, and can be used on a wide scale to benefit a broad range of individuals throughout society, such as the elderly, individuals with impaired plantarflexor muscle strength, or recreational users. In summary, this paper demonstrates how an unpowered ankle exoskeleton could be redesigned to more seamlessly integrate into daily life, while still providing performance benefits for common locomotion tasks.

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.

User satisfaction with lower limb wearable robotic exoskeletons

Objective: To provide the results of a robotic exoskeleton user satisfaction questionnaire completed by participants utilizing two robotic exoskeletons.Method: Seven individuals with physical disabilities engaged in two exoskeleton-assisted training phases with the REX and the Ekso 1.1 (Ekso), after which they completed a user satisfaction questionnaire. The questionnaire consisted of structured items with a Likert scale, which were averaged and compared, as well as free response questions, which were interpreted thematically.Results: Participants reported some differences in user satisfaction between the two exoskeletons. They indicated higher satisfaction with transferring in and out of the REX and with its appearance and higher satisfaction with the transportability of the Ekso. Expectations for exoskeleton use were relatively similar for the two devices, with some exceptions. Whereas participants indicated that many changes should be made to both exoskeletons, they reported that some were more necessary for the REX and others were more necessary for the Ekso. Participants reported that they would be somewhat likely to use both exoskeletons at home and in the community if they were available.Conclusions: This brief report provides an initial comparison of user satisfaction with two exoskeletons, thereby contributing to the growing body of literature in this area.Implications for rehabiliationContributes to the literature on user satisfaction with robotic exoskeletons Implications for rehabilitationEmphasizes the role of user/participant/patient feedback in rehabilitation researchProvides user satisfaction questionnaire items that can be used in future studies.

Questionnaire results of user experiences with wearable exoskeletons and their preferences for sensory feedback

BACKGROUND

Wearable exoskeletons can be a powerful tool for the facilitation of ambulation of complete Spinal Cord Injury (SCI) subjects, which has several psychological and physical advantages. However, exoskeleton control is difficult for this group of users and requires a long period of training. People with SCI not only lack the motor control, but also miss the sensory information from below the level of the lesion, which is for example very important in their perception of body posture and makes balancing with an exoskeleton difficult. It is hypothesized that through sensory substitution part of the missing sensory information can be provided and might thereby improve the control of an exoskeleton. However, it is not known which information would be most important to receive while using an exoskeleton and how this feedback should be provided.

METHODS

To investigate the preferences of users of an exoskeleton, a questionnaire was filled out by 10 SCI subjects who underwent a training program with a commercial exoskeleton (ReWalk). The questionnaire consisted of questions about the use of the exoskeleton to identify which information is missing and which instructions from the therapists were needed to be able to control the exoskeleton. The second part of the questionnaire focused on the possibilities of sensory feedback and preferences for stimulation methods (auditory, vibrotactile or visual) and feedback timing (discrete or continuous) were investigated. Furthermore, six options for feedback parameters (step initiation, continuous and discrete gait phases, foot position and mediolateral and anteroposterior weight shift) were proposed and the respondents were asked to indicate their preferences.

RESULTS

Three feedback parameters (feedback about mediolateral and anteroposterior weight shift and feedback about step initiation) were considered as possibly helpful by the respondents. Furthermore, there were slight preferences for the use of vibrotactile (over auditory and visual) and discrete (over continuous) feedback.

CONCLUSIONS

The answers of the respondents on the optimal feedback parameters were rather variable and therefore it is recommended to let the users choose their preferred feedback system during a training session with several feedback options. However, there are slight preferences for the use of vibrotactile stimulation provided in a discrete way.