Re-defining wearable robots: a multidisciplinary approach towards a unified terminology.

Effective communication is especially important in the wearable robots (WRs) community, which encloses a great variety of devices across different application domains, e.g., healthcare, occupational, and consumer. In this paper we present a vocabulary of terms with the aim to create a common understanding of terms and concepts among the different fields of expertise relevant in the WRs community. Our goal is to develop shared documentation that could serve as a reference to facilitate the use of accepted definitions in the field. The presented vocabulary is the result of different focus group discussions among experts in the field. The resulting document was then validated by presenting it to the WR community through an online survey. The results of the survey highlight a strong agreement in terms of acceptance of the vocabulary, its usefulness, and applicability of the proposed definitions as well as an overall appreciation for its purpose and target. This work represents a pilot study providing unique material for the WR community, encouraging the use of shared agreed definitions. The reported version of the vocabulary has been made available as a live document in a github repository, for public commenting and further improvements.

Relevance of hazards in exoskeleton applications: a survey-based enquiry.

Exoskeletons are becoming the reference technology for assistance and augmentation of human motor functions in a wide range of application domains. Unfortunately, the exponential growth of this sector has not been accompanied by a rigorous risk assessment (RA) process, which is necessary to identify the major aspects concerning the safety and impact of this new technology on humans. This situation may seriously hamper the market uptake of new products. This paper presents the results of a survey that was circulated to understand how hazards are considered by exoskeleton users, from research and industry perspectives. Our analysis aimed to identify the perceived occurrence and the impact of a sample of generic hazards, as well as to collect suggestions and general opinions from the respondents that can serve as a reference for more targeted RA. Our results identified a list of relevant hazards for exoskeletons. Among them, misalignments and unintended device motion were perceived as key aspects for exoskeletons' safety. This survey aims to represent a first attempt in recording overall feedback from the community and contribute to future RAs and the identification of better mitigation strategies in the field.

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

OBJECTIVE: To explore user-centered design methods currently implemented during development of lower limb wearable robots and how they are utilized during different stages of product development. BACKGROUND: Currently, there appears to be a lack of standardized frameworks for evaluation methods and design requirements to implement effective user-centered design for safe and effective clinical or ergonomic system application. METHOD: Responses from a total of 191 experts working in the field of lower limb exoskeletons were analyzed in this exploratory survey. Descriptive statistics were used to present responses and measures of frequency, and chi-square tests were used to contrast the answers of respondents who identified as clinicians versus engineers. RESULTS: A vast majority of respondents involve users in their development, in particular at the initial and iterative stages, although some differences were found between disciplines. A variety of methods and metrics are used to capture feedback from users and test devices, and although valuable, some methods used may not be based on validated measures. Guidelines regarding tests on safety of exoskeletons also lack standardization. CONCLUSION: There seems to be a consensus among experts regarding the importance of a user-centered approach in exoskeleton development; however, standardized frameworks with regard to appropriate testing methods and design approaches are lacking. Such frameworks should consider an interdisciplinary focus on the needs and safety of the intended user during each iteration of the process. APPLICATION: This exploratory study provides an overview of current practice among engineers and clinicians regarding the user-centered design of exoskeletons. Limitations and recommendations for future directions are identified.

Robot-supported assessment of balance in standing and walking.

Clinically useful and efficient assessment of balance during standing and walking is especially challenging in patients with neurological disorders. However, rehabilitation robots could facilitate assessment procedures and improve their clinical value. We present a short overview of balance assessment in clinical practice and in posturography. Based on this overview, we evaluate the potential use of robotic tools for such assessment. The novelty and assumed main benefits of using robots for assessment are their ability to assess 'severely affected' patients by providing assistance-as-needed, as well as to provide consistent perturbations during standing and walking while measuring the patient's reactions. We provide a classification of robotic devices on three aspects relevant to their potential application for balance assessment: 1) how the device interacts with the body, 2) in what sense the device is mobile, and 3) on what surface the person stands or walks when using the device. As examples, nine types of robotic devices are described, classified and evaluated for their suitability for balance assessment. Two example cases of robotic assessments based on perturbations during walking are presented. We conclude that robotic devices are promising and can become useful and relevant tools for assessment of balance in patients with neurological disorders, both in research and in clinical use. Robotic assessment holds the promise to provide increasingly detailed assessment that allows to individually tailor rehabilitation training, which may eventually improve training effectiveness.

Clinical Feasibility of Applying Immersive Virtual Reality during Robot-Assisted Gait Training for Individuals with Neurological Diseases: A Pilot Study.

BACKGROUND: Immersive virtual reality has the potential to motivate and challenge patients who need and want to relearn movements in the process of neurorehabilitation. OBJECTIVE: The aim of this study was to evaluate the feasibility and user acceptance of an innovative immersive virtual reality system (head-mounted display) used in combination with robot-assisted gait training in subjects suffering from neurological diseases. METHODS: Fifteen participants suffering from cerebrovascular accident or spinal cord injury completed a single session of immersive virtual reality using a head-mounted display during a Lokomat® gait session. Training parameters and safety indicators were collected, and acceptance was investigated among participants and therapists. RESULTS: The results suggest that an immersive virtual reality system is feasible in terms of safety and tolerance. Furthermore, the very positive overall acceptance of the system suggests that it has the potential to be included in a robot-assisted gait training session using Lokomat®. CONCLUSION: Overall, this study demonstrates that a fully immersive virtual reality system based on a head-mounted display is both feasible and well received by cerebrovascular accident and spinal cord injury patients and their therapists during robot-assisted gait training. This study suggests that such a virtual reality system could be a viable alternative to the screen-based training games currently used in neurorehabilitation. It may be especially suitable for enhancing patient motivation and adherence to training, particularly if the application is enjoyable and not mentally taxing.

Challenges and solutions for application and wider adoption of wearable robots.

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

Benchmarking Wearable Robots: Challenges and Recommendations From Functional, User Experience, and Methodological Perspectives.

Wearable robots (WRs) are increasingly moving out of the labs toward real-world applications. In order for WRs to be effectively and widely adopted by end-users, a common benchmarking framework needs to be established. In this article, we outline the perspectives that in our opinion are the main determinants of this endeavor, and exemplify the complex landscape into three areas. The first perspective is related to quantifying the technical performance of the device and the physical impact of the device on the user. The second one refers to the understanding of the user's perceptual, emotional, and cognitive experience of (and with) the technology. The third one proposes a strategic path for a global benchmarking methodology, composed by reproducible experimental procedures representing real-life conditions. We hope that this paper can enable developers, researchers, clinicians and end-users to efficiently identify the most promising directions for validating their technology and drive future research efforts in the short and medium term.

Real time computation of Centroidal Momentum while human walking in the lower limbs rehabilitation exoskeleton: Preliminary trials.

In EU-funded BALANCE project, developing a stability index which can be employed to estimate actual state of balance of both healthy and neurologically impaired humans' walking in exoskeleton was one of scientific tasks. In the task, Centroidal Momentum (CM), referring to linear and angular momenta at Center of Mass (CoM), has raised as a potential index for such purpose. While our past studies have presented analysis results of CM in offline and online (real time) manners for walking of healthy human and stroke patients, in this study, we present real time computation of CM in exoskeleton-supported walking, specifically with healthy subjects. Experimental setup consists of LOPES II, a treadmill-based robotic gait training exoskeleton for lower limbs rehabilitation developed by Twente University, and commercially available IMUs (Inertial Measurement Units)-based full body motion capture suits from Xsens. CM was computed and demonstrated in two walking conditions: unperturbed walking and walking with unexpected pelvic perturbations in lateral direction. While electromagnetic fields (EMF) from LOPES II exoskeleton affected signals of IMUs in the motion capture suit, the results show the potential applicability of the CM as a sort of stability index for human walking in the exoskeleton.

Fixating the pelvis in the horizontal plane affects gait characteristics.

In assistive devices for neuro-rehabilitation, natural human motions are partly restricted by the device. This may affect the normality of walking during training. This research determines effects on gait of fixating the pelvis translations in the horizontal plane during treadmill walking. Direct effects on the motion of the pelvis and external forces acting on the pelvis were measured. Several gait descriptors (step parameters, trunk angles and a ground reaction force parameter) were defined and measured to indicate changes. We observed the effect of the pelvis fixation on these parameters while varying gait velocity (0.35, 0.60 and 0.90 m/s). It was shown that the fixation caused a reduction of step width by 33%, and an increase of step length of 19%. Sagittal and coronal trunk rotations changed with +68% and -54% respectively. The fixation also significantly changed the effect of speed on most descriptors. It can therefore be concluded that a fixation of the pelvis severely affects gait dynamics and that it should be avoided if natural walking should be possible during training.

Design and evaluation of the LOPES exoskeleton robot for interactive gait rehabilitation.

This paper introduces a newly developed gait rehabilitation device. The device, called LOPES, combines a freely translatable and 2-D-actuated pelvis segment with a leg exoskeleton containing three actuated rotational joints: two at the hip and one at the knee. The joints are impedance controlled to allow bidirectional mechanical interaction between the robot and the training subject. Evaluation measurements show that the device allows both a "patient-in-charge" and "robot-in-charge" mode, in which the robot is controlled either to follow or to guide a patient, respectively. Electromyography (EMG) measurements (one subject) on eight important leg muscles, show that free walking in the device strongly resembles free treadmill walking; an indication that the device can offer task-specific gait training. The possibilities and limitations to using the device as gait measurement tool are also shown at the moment position measurements are not accurate enough for inverse-dynamical gait analysis.

Clinical validation of a novel postural support device for hospitalized sub-acute post-stroke wheelchair users.

PURPOSE: We present a novel wheelchair posture support device (WPSD) and its clinical validation. The device was developed in order to assure correct sitting posture and to reduce the time spent by caregivers for re-positioning of hospitalized, wheelchair-bound, post-acute stroke patients. METHOD: The device was validated with 16 subjects during a period of 5 days in which use of the device was compared with regular care practice. RESULTS: The device was used for the five consecutive days in 69% of patients, while for 6% it was not suitable; 25% did not complete the 5 days for reasons unrelated to the device. Caregivers needed to re-position the patients that used the device for the full 5 days (n = 11) on an average 52% less often when using the device, as compared to regular practice. Furthermore, the device was rated as usable and functional by the caregivers while significantly reducing perception of trunk and shoulder pain in patients during its use. CONCLUSIONS: The newly designed WPSD is a valuable system for the improvement of medical assistance to wheelchair-bound post-stroke patients by reducing pain and number of re-positioning manoeuvres. The WPSD might be applicable to any group of patients who need posture control in either wheelchair or common chair with arms support. IMPLICATIONS FOR REHABILITATION Advanced supports and cushions that can be shaped to individual needs, may help assure correct sitting posture in wheelchair-bound post-acute stroke patients. Advanced supports and cushions that can be shaped to individual needs, may reduce the number of times a caregiver has to re-position a hospitalized wheelchair-bound post-acute stroke patient on overall average by 52%. Advanced personalized supports and cushions may improve sitting comfort and reduce pain complaints for post-acute hospitalized stroke patients using a wheelchair.

Variable Stiffness Structure for limb attachment.

In robotic rehabilitation, the way of attaching the robotic device to the users' limb constitutes a crucial element of product quality, particularly for assuring good fitting, comfort, accuracy, usability, and safety. In this article, we present a new technological concept - 'Variable Stiffness Structure' - allowing for an improvement of these aspects in the 'robotic device to limb' - connection by offering a compound of materials that are together able to switch from a flexible textile-like state to a more rigid state by applying negative pressure. The paper describes the concept and the basic behaviour of the material, based on experiments.

Variable structure pantograph mechanism with spring suspension system for comprehensive upper-limb haptic movement training.

Numerous haptic devices have been developed for upper-limb neurorehabilitation, but their widespread use has been largely impeded because of complexity and cost. Here, we describe a variable structure pantograph mechanism combined with a spring suspension system that produces a versatile rehabilitation robot, called Universal Haptic Pantograph, for movement training of the shoulder, elbow, and wrist. The variable structure is a 5-degree-of-freedom (DOF) mechanism composed of 7 joints, 11 joint axes, and 3 configurable joint locks that reduce the number of system DOFs to between 0 and 3. The resulting device has eight operational modes: Arm, Wrist, ISO (isometric) 1, ISO 2, Reach, Lift 1, Lift 2, and Steer. The combination of available work spaces (reachable areas) shows a high suitability for movement training of most upper-limb activities of daily living. The mechanism, driven by series elastic actuators, performs similarly in all operational modes, with a single control scheme and set of gains. Thus, a single device with minimal setup changes can be used to treat a variety of upper-limb impairments that commonly afflict veterans with stroke, traumatic brain injury, or other direct trauma to the arm. With appropriately selected design parameters, the developed multimode haptic device significantly reduces the costs of robotic hardware for full-arm rehabilitation while performing similarly to that of single-mode haptic devices. We conducted case studies with three patients with stroke who underwent clinical training using the developed mechanism in Arm, Wrist, and/or Reach operational modes. We assessed outcomes using Fugl-Meyer Motor Assessment and Wolf Motor Function Test scores showing that upper-limb ability improved significantly following training sessions.

The Effects on Kinematics and Muscle Activity of Walking in a Robotic Gait Trainer During Zero-Force Control.

"Assist as needed" control algorithms promote activity of patients during robotic gait training. Implementing these requires a free walking mode of a device, as unassisted motions should not be hindered. The goal of this study was to assess the normality of walking in the free walking mode of the LOPES gait trainer, an 8 degrees-of-freedom lightweight impedance controlled exoskeleton. Kinematics, gait parameters and muscle activity of walking in a free walking mode in the device were compared with those of walking freely on a treadmill. Average values and variability of the spatio-temporal gait variables showed no or small (relative to cycle-to-cycle variability) changes and the kinematics showed a significant and relevant decrease in knee angle range only. Muscles involved in push off showed a small decrease, whereas muscles involved in acceleration and deceleration of the swing leg showed an increase of their activity. Timing of the activity was mainly unaffected. Most of the observed differences could be ascribed to the inertia of the exoskeleton. Overall, walking with the LOPES resembled free walking, although this required several adaptations in muscle activity. These adaptations are such that we expect that Assist as Needed training can be implemented in LOPES.