Systematic Evaluation of a Knee Exoskeleton Misalignment Compensation Mechanism Using a Robotic Dummy Leg.

The objective and quantitative assessment of physical human-exoskeletons interaction (pHEI) represents a pressing necessity in the wearable robots field. This process remains of difficult execution, especially for early stage devices, in which the inclusion of human testing could pose ethical and safety concerns. This manuscript proposes a methodology for pHEI assessment based on an active dummy leg named Leg Replica, which is able to sense interaction forces while wearing an exoskeleton. We tested this methodology on a wearable active knee exoskeleton prototype, with the goal to evaluate the effects of a misalignment compensation mechanism. Through this methodology, it was possible to show how the misalignment compensation mechanism was able to reduce the interaction forces during passive exoskeleton motion. Such reduction was less evident when the exoskeleton was active. The tests allowed to identify specific points of improvements for the exoskeleton, enabling a more specific upgrade of the device based on these experimental results. This study demonstrates the ability of the proposed methodology to objectively benchmark different aspects of pHEI, and to accelerate the iterative development of new devices prior to human testing.

Motion Biomarkers Showing Maximum Contrast Between Healthy Subjects and Parkinson's Disease Patients Treated With Deep Brain Stimulation of the Subthalamic Nucleus. A Pilot Study.

Background: Classic motion abnormalities in Parkinson's disease (PD), such as tremor, bradykinesia, or rigidity, are well-covered by standard clinical assessments such as the Unified Parkinson's Disease Rating Scale (UPDRS). However, PD includes motor abnormalities beyond the symptoms and signs as measured by UPDRS, such as the lack of anticipatory adjustments or compromised movement smoothness, which are difficult to assess clinically. Moreover, PD may entail motor abnormalities not yet known. All these abnormalities are quantifiable via motion capture and may serve as biomarkers to diagnose and monitor PD. Objective: In this pilot study, we attempted to identify motion features revealing maximum contrast between healthy subjects and PD patients with deep brain stimulation (DBS) of the nucleus subthalamicus (STN) switched off and on as the first step to develop biomarkers for detecting and monitoring PD patients' motor symptoms. Methods: We performed 3D gait analysis in 7 out of 26 PD patients with DBS switched off and on, and in 25 healthy control subjects. We computed feature values for each stride, related to 22 body segments, four time derivatives, left-right mean vs. difference, and mean vs. variance across stride time. We then ranked the feature values according to their distinguishing power between PD patients and healthy subjects. Results: The foot and lower leg segments proved better in classifying motor anomalies than any other segment. Higher degrees of time derivatives were superior to lower degrees (jerk > acceleration > velocity > displacement). The averaged movements across left and right demonstrated greater distinguishing power than left-right asymmetries. The variability of motion was superior to motion's absolute values. Conclusions: This small pilot study identified the variability of a smoothness measure, i.e., jerk of the foot, as the optimal signal to separate healthy subjects' from PD patients' gait. This biomarker is invisible to clinicians' naked eye and is therefore not included in current motor assessments such as the UPDRS. We therefore recommend that more extensive investigations be conducted to identify the most powerful biomarkers to characterize motor abnormalities in PD. Future studies may challenge the composition of traditional assessments such as the UPDRS.

The Reliance on Vestibular Information During Standing Balance Control Decreases With Severity of Vestibular Dysfunction.

The vestibular system is involved in gaze stabilization and standing balance control. However, it is unclear whether vestibular dysfunction affects both processes to a similar extent. Therefore, the objective of this study was to determine how the reliance on vestibular information during standing balance control is related to gaze stabilization deficits in patients with vestibular dysfunction. Eleven patients with vestibular dysfunction and twelve healthy subjects were included. Gaze stabilization deficits were established by spontaneous nystagmus examination, caloric test, rotational chair test, and head impulse test. Standing balance control was assessed by measuring the body sway (BS) responses to continuous support surface rotations of 0.5° and 1.0° peak-to-peak while subjects had their eyes closed. A balance control model was fitted on the measured BS responses to estimate balance control parameters, including the vestibular weight, which represents the reliance on vestibular information. Using multivariate analysis of variance, balance parameters were compared between patients with vestibular dysfunction and healthy subjects. Robust regression was used to investigate correlations between gaze stabilization and the vestibular weight. Our results showed that the vestibular weight was smaller in patients with vestibular dysfunction than in healthy subjects (F = 7.67, p = 0.011). The vestibular weight during 0.5° peak-to-peak support surface rotations decreased with increasing spontaneous nystagmus eye velocity (ρ = -0.82, p < 0.001). In addition, the vestibular weight during 0.5° and 1.0° peak-to-peak support surface rotations decreased with increasing ocular response bias during rotational chair testing (ρ = -0.72, p = 0.02 and ρ = -0.67, p = 0.04, respectively). These findings suggest that the reliance on vestibular information during standing balance control decreases with the severity of vestibular dysfunction. We conclude that particular gaze stabilization tests may be used to predict the effect of vestibular dysfunction on standing balance control.

Neuroimaging of an attention demanding dual-task during dynamic postural control.

Cognitive tasks impact postural control when performed concurrently as dual-tasks. This is presumed to result from capacity limitations in relevant brain regions. We used functional near-infrared spectroscopy (fNIRS) to measure brain activation of the left motor, temporal, and dorsal-lateral prefrontal brain regions of younger (n=6) and older (n=10) adults. Brain activation was measured during an auditory choice reaction task (CRT) and standing on a dynamic posturography platform, both as single-tasks and concurrently as dual-task. Body sway was assessed by median absolute deviation (MAD) of anterior-posterior translation of the center of mass (COM). Brain activation was measured as changes in oxy-hemoglobin by fNIRS. During both single- and dual-task conditions, we found that older adults had greater brain activation relative to younger adults. During dual task performance, the total activation was less than expected from the sum of individual conditions for both age groups, indicating a dual-task interference (reduction in younger adults=53% [p=0.02]; in older adults=53%; [p=0.008]). This reduction was greater for the activation attributable to the postural task (reduction younger adults=75% [p=0.03]; older adults=59% [p=0.005]) compared to the CRT task (reduction younger adults=10%, [p=0.6]; older adults=7.3%, [p=0.5]) in both age groups. Activation reduction was not accompanied by any significant changes in body sway in either group (older adults: single-task MAD=0.94cm, dual-task MAD=1.10cm, p=0.20; younger adults: single-task RMS=0.95cm, dual-task MAD=1.08cm, p=0.14). Our results indicate that neural resources devoted to postural control are reduced under dual-task conditions that engage attention.

Correlations between Motor Symptoms across Different Motor Tasks, Quantified via Random Forest Feature Classification in Parkinson's Disease.

BACKGROUND: Objective assessments of Parkinson's disease (PD) patients' motor state using motion capture techniques are still rarely used in clinical practice, even though they may improve clinical management. One major obstacle relates to the large dimensionality of motor abnormalities in PD. We aimed to extract global motor performance measures covering different everyday motor tasks, as a function of a clinical intervention, i.e., deep brain stimulation (DBS) of the subthalamic nucleus. METHODS: We followed a data-driven, machine-learning approach and propose performance measures that employ Random Forests with probability distributions. We applied this method to 14 PD patients with DBS switched-off or -on, and 26 healthy control subjects performing the Timed Up and Go Test (TUG), the Functional Reach Test (FRT), a hand coordination task, walking 10-m straight, and a 90° curve. RESULTS: For each motor task, a Random Forest identified a specific set of metrics that optimally separated PD off DBS from healthy subjects. We noted the highest accuracy (94.6%) for standing up. This corresponded to a sensitivity of 91.5% to detect a PD patient off DBS, and a specificity of 97.2% representing the rate of correctly identified healthy subjects. We then calculated performance measures based on these sets of metrics and applied those results to characterize symptom severity in different motor tasks. Task-specific symptom severity measures correlated significantly with each other and with the Unified Parkinson's Disease Rating Scale (UPDRS, part III, correlation of r2 = 0.79). Agreement rates between different measures ranged from 79.8 to 89.3%. CONCLUSION: The close correlation of PD patients' various motor abnormalities quantified by different, task-specific severity measures suggests that these abnormalities are only facets of the underlying one-dimensional severity of motor deficits. The identification and characterization of this underlying motor deficit may help to optimize therapeutic interventions, e.g., to "automatically" adapt DBS settings in PD patients.

Biomechanical Effects of Stiffness in Parallel With the Knee Joint During Walking.

The human knee behaves similarly to a linear torsional spring during the stance phase of walking with a stiffness referred to as the knee quasi-stiffness. The spring-like behavior of the knee joint led us to hypothesize that we might partially replace the knee joint contribution during stance by utilizing an external spring acting in parallel with the knee joint. We investigated the validity of this hypothesis using a pair of experimental robotic knee exoskeletons that provided an external stiffness in parallel with the knee joints in the stance phase. We conducted a series of experiments involving walking with the exoskeletons with four levels of stiffness, including 0%, 33%, 66%, and 100% of the estimated human knee quasi-stiffness, and a pair of joint-less replicas. The results indicated that the ankle and hip joints tend to retain relatively invariant moment and angle patterns under the effects of the exoskeleton mass, articulation, and stiffness. The results also showed that the knee joint responds in a way such that the moment and quasi-stiffness of the knee complex (knee joint and exoskeleton) remains mostly invariant. A careful analysis of the knee moment profile indicated that the knee moment could fully adapt to the assistive moment; whereas, the knee quasi-stiffness fully adapts to values of the assistive stiffness only up to ∼80%. Above this value, we found biarticular consequences emerge at the hip joint.

Preliminary investigation of effects of a quasi-passive knee exoskeleton on gait energetics.

In this paper, we explain that the human knee behavior in the weight acceptance phase of gait (first ~40% of gait cycle) resembles that of a linear torsional spring. This led us to study the effects of the assistance provided by a pair of quasi-passive knee exoskeletons, which implement springs in parallel with the knee joints in the weight acceptance phase. Using the exoskeletons in a series of experiments on seven participants, we found that the exoskeleton mildly but non-significantly reduces the metabolic power of walking. We also found that the metabolic power of walking is significantly correlated with both the positive rate of moment generation and positive mechanical power of the lower extremity joints. This suggests that augmenting exoskeletons can aim to reduce both the muscle force and work generation to reduce the metabolic cost of walking.

Design and evaluation of a quasi-passive knee exoskeleton for investigation of motor adaptation in lower extremity joints.

In this study, we describe the mechanical design and control scheme of a quasi-passive knee exoskeleton intended to investigate the biomechanical behavior of the knee joint during interaction with externally applied impedances. As the human knee behaves much like a linear spring during the stance phase of normal walking gait, the exoskeleton implements a spring across the knee in the weight acceptance (WA) phase of the gait while allowing free motion throughout the rest of the gait cycle, accomplished via an electromechanical clutch. The stiffness of the device is able to be varied by swapping springs, and the timing of engagement/disengagement changed to accommodate different loading profiles. After describing the design and control, we validate the mechanical performance and reliability of the exoskeleton through cyclic testing on a mechanical knee simulator. We then describe a preliminary experiment on three healthy adults to evaluate the functionality of the device on both left and right legs. The kinetic and kinematic analyses of these subjects show that the exoskeleton assistance can partially/fully replace the function of the knee joint and obtain nearly invariant moment and angle profiles for the hip and ankle joints, and the overall knee joint and exoskeleton complex under the applied moments of the exoskeleton versus the control condition, implying that the subjects undergo a considerable amount of motor adaptation in their lower extremities to the exoskeletal impedances, and encouraging more in-depth future experiments with the device.

Biomechanical considerations in the design of lower limb exoskeletons.

This paper presents an analysis of the human biomechanical considerations related to the development of lower limb exoskeletons. Factors such as kinematic alignment and compatibility, joint range of motion, maximum torque, and joint bandwidth are discussed in the framework of a review of the design specifications for exoskeleton prototypes discussed in the literature. From this analysis, we discuss major gaps in the research related to the topic and how those might be filled.

On the mechanics of the ankle in the stance phase of the gait.

In this paper we explore the mechanical behavior of the ankle in the progression stage of stance during normal walking. We show that the torque/angle behavior of the ankle during this stage can be approximated by an augmented linear torsional spring. The mechanical parameters completely specifying this spring are identified, including stiffness, amount of rotation, and angle of zero moment. The effect of load weight, gait speed and ground slope on those parameters and the propulsive work of the ankle are also discussed. The findings of this paper can be applied to the design of leg orthoses, prostheses and exoskeletons, and bipedal robots in general, allowing the implementation of human-like leg compliance during stance with a relatively simple latched-spring mechanism.

Stiffness and damping in postural control increase with age.

Upright balance is believed to be maintained through active and passive mechanisms, both of which have been shown to be impacted by aging. A compensatory balance response often observed in older adults is increased co-contraction, which is generally assumed to enhance stability by increasing joint stiffness. We investigated the effect of aging on standing balance by fitting body sway data to a previously developed postural control model that includes active and passive stiffness and damping parameters. Ten young (24 +/- 3 years) and seven older (75 +/- 5 years) adults were exposed during eyes-closed stance to perturbations consisting of lateral pseudorandom floor tilts. A least-square fit of the measured body sway data to the postural control model found significantly larger active stiffness and damping model parameters in the older adults. These differences remained significant even after normalizing to account for different body sizes between the young and older adult groups. An age effect was also found for the normalized passive stiffness, but not for the normalized passive damping parameter. This concurrent increase in active stiffness and damping was shown to be more stabilizing than an increase in stiffness alone, as assessed by oscillations in the postural control model impulse response.

Medial-lateral postural control in older adults exhibits increased stiffness and damping.

Older adults often exhibit increased co-contraction in response to a balance perturbation. This response is generally thought to enhance stability by increasing joint stiffness. We investigated the issue of increased stiffness in postural control by exposing seven older (75 +/- 5 y) and ten young (24 +/- 3 y) adults to pseudo-random medial-lateral (ML) floor tilts, and then fitting the measured ML body sway data to a previously-developed postural control model that includes stiffness and damping parameters. Significant increases were found in both parameters in the older adults compared to the young adults. This concurrent increase in stiffness and damping is more stabilizing than an increase in stiffness alone, which can lead to resonances.

Stimulus-dependent changes in the vestibular contribution to human postural control.

Humans maintain stable stance in a wide variety of environments. This robust behavior is thought to involve sensory reweighting whereby the nervous system adjusts the relative contribution of sensory sources used to control stance depending on environmental conditions. Based on prior experimental and modeling results, we developed a specific quantitative representation of a sensory reweighting hypothesis that predicts that a given reduction in the contribution from one sensory system will be accompanied by a corresponding increase in the contribution from different sensory systems. The goal of this study was to test this sensory-reweighting hypothesis using measures that quantitatively assess the relative contributions of the proprioceptive and graviceptive (vestibular) systems to postural control during eyes-closed stance in different test conditions. Medial/lateral body sway was evoked by side-to-side rotation of the support surface (SS) while simultaneously delivering a pulsed galvanic vestibular stimulus (GVS) through electrodes behind the ears. A model-based interpretation of sway evoked by SS rotations provided estimates of the proprioceptive weighting factor, Wp, and showed that Wp declined with increasing SS amplitude. If the sensory-reweighting hypothesis is true, then the decline in Wp should be accompanied by a corresponding increase in Wp, the graviceptive weighting factor, and responses to the GVS should increase in proportion to the value of Wp derived from responses to SS rotations. Results were consistent with the predictions of the proposed sensory-reweighting hypothesis. GVS-evoked sway increased with increasing SS amplitude, and Wp measures derived from responses to GVS and from responses to SS rotations were highly correlated.