Posts Tagged gait rehabilitation

[ARTICLE] Systematic review on wearable lower-limb exoskeletons for gait training in neuromuscular impairments – Full Text

Abstract

Gait disorders can reduce the quality of life for people with neuromuscular impairments. Therefore, walking recovery is one of the main priorities for counteracting sedentary lifestyle, reducing secondary health conditions and restoring legged mobility. At present, wearable powered lower-limb exoskeletons are emerging as a revolutionary technology for robotic gait rehabilitation. This systematic review provides a comprehensive overview on wearable lower-limb exoskeletons for people with neuromuscular impairments, addressing the following three questions: (1) what is the current technological status of wearable lower-limb exoskeletons for gait rehabilitation?, (2) what is the methodology used in the clinical validations of wearable lower-limb exoskeletons?, and (3) what are the benefits and current evidence on clinical efficacy of wearable lower-limb exoskeletons? We analyzed 87 clinical studies focusing on both device technology (e.g., actuators, sensors, structure) and clinical aspects (e.g., training protocol, outcome measures, patient impairments), and make available the database with all the compiled information. The results of the literature survey reveal that wearable exoskeletons have potential for a number of applications including early rehabilitation, promoting physical exercise, and carrying out daily living activities both at home and the community. Likewise, wearable exoskeletons may improve mobility and independence in non-ambulatory people, and may reduce secondary health conditions related to sedentariness, with all the advantages that this entails. However, the use of this technology is still limited by heavy and bulky devices, which require supervision and the use of walking aids. In addition, evidence supporting their benefits is still limited to short-intervention trials with few participants and diversity among their clinical protocols. Wearable lower-limb exoskeletons for gait rehabilitation are still in their early stages of development and randomized control trials are needed to demonstrate their clinical efficacy.

Background

Gait disorders affect approximately 60% of patients with neuromuscular disorders [1] and generally have a high impact on their quality of life [2]. Moreover, immobility and loss of independence for performing basic activities of daily living results in patients being restricted to a sedentary lifestyle. This lack of physical activity increases the risk of developing secondary health conditions (SHCs), such as respiratory and cardiovascular complications, bowel/bladder dysfunction, obesity, osteoporosis and pressure ulcers [3,4,5,6,7]; which can further reduce the patients’ life expectancy [34]. Therefore, walking recovery is one of the main rehabilitation goals for patients with neuromuscular impairments [89].

Robotic gait rehabilitation appeared 25 years ago as an alternative to conventional manual gait training. Compared with conventional therapy, robotic gait rehabilitation can deliver highly controlled, repetitive and intensive training in an engaging environment [10], reduce the physical burden for the therapist, and provide objective and quantitative assessments of the patients’ progression [11]. The use of gait rehabilitation robots began in 1994 [12] with the development of Lokomat [13]. Since then, different rehabilitation robots have been developed and can be classified into grounded exoskeletons (e.g., Lokomat [14], LOPES [15], ALEX [16]), end-effector devices (e.g., Gait Trainer [17], Haptic Walker [18]), and wearable exoskeletons (e.g., ReWalk [19], Ekso [20], Indego [21]) [12]. In addition, there have been recent developments towards “soft exoskeletons” or “exosuits” which use soft actuation systems and/or structures to assist the walking function [22,23,24,25]. Despite these developments, to date the optimal type of rehabilitation robot for a specific user and neuromuscular impairment still remains unclear [26].

Wearable exoskeletons are emerging as revolutionary devices for gait rehabilitation due to both the active participation required from the user, which promotes physical activity [27], and the possibility of being used as an assistive device in the community. The number of studies on wearable exoskeletons during the past 10 years has seen a rapid increase, following the general tendency now towards rehabilitation robots [28]. Some of these devices already have FDA approval and/or CE mark, and are commercially available, whereas many others are still under development.

There have been several reviews surveying the field of wearable exoskeletons for gait rehabilitation. Some of these reviews have focused on reviewing the technological aspects of exoskeletons from a general perspective [2930], while others have focused on specific aspects such as the control strategies [31] or the design of specific joints [32]. A selection of reviews have focused on surveying the evidence on effectiveness and usability of exoskeletons for clinical neurorehabilitation in general [3334], or for a specific pathology such as spinal cord injury (SCI) [3034] or stroke [11].

This review provides a comprehensive overview on wearable lower-limb powered exoskeletons for over ground training, without body weight support, that are intended for use with people who have gait disorders due to neuromuscular impairments. In comparison with other reviews, we analyse a wide range of aspects of wearable exoskeletons, from their technology to their clinical evidence, for different types of pathologies. This systematic review was carried out to address the following questions: (1) what is the current technological status of wearable lower-limb exoskeletons for gait rehabilitation?, (2) what are the benefits and risks for exoskeleton users?, and (3) what is the current evidence on clinical efficacy for wearable exoskeletons?

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Fig. 1 Four-phase flow diagram of the literature selection process according to PRISMA guidelines. From 884, finally 87 studies were selected, of which 71 were identified as clinical trials according to the Clinical Trial definition proposed by the National Institutes of Health (NIH) [35] (see Additional file 1). The 87 studies were grouped in three categories according to the pathology treated in the study: Spinal Cord injury (n=54, stroke (n=22 and other pathologies (n=11; poliomyelitis: 3, cerebral palsy: 3, multiple sclerosis: 2, brain tumor surgery: 1, spinocerebellar degeneration: 1, and traumatic brain injury: 1)

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[ARTICLE] Evaluating the effect of immersive virtual reality technology on gait rehabilitation in stroke patients: a study protocol for a randomized controlled trial – Full Text

Abstract

Background

The high incidence of cerebral apoplexy makes it one of the most important causes of adult disability. Gait disorder is one of the hallmark symptoms in the sequelae of cerebral apoplexy. The recovery of walking ability is critical for improving patients’ quality of life. Innovative virtual reality technology has been widely used in post-stroke rehabilitation, whose effectiveness and safety have been widely verified. To date, however, there are few studies evaluating the effect of immersive virtual reality on stroke-related gait rehabilitation. This study outlines the application of immersive VR-assisted rehabilitation for gait rehabilitation of stroke patients for comparative evaluation with traditional rehabilitation.

Methods

The study describes a prospective, randomized controlled clinical trial. Thirty-six stroke patients will be screened and enrolled as subjects within 1 month of initial stroke and randomized into two groups. The VRT group (n = 18) will receive VR-assisted training (30 min) 5 days/week for 3 weeks. The non-VRT group (n = 18) will receive functional gait rehabilitation training (30 min) 5 days/week for 3 weeks. The primary outcomes and secondary outcomes will be conducted before intervention, 3 weeks after intervention, and 6 months after intervention. The primary outcomes will include time “up & go” test (TUGT). The secondary outcomes will include MMT muscle strength grading standard (MMT), Fugal-Meyer scale (FMA), motor function assessment scale (MAS), improved Barthel index scale (ADL), step with maximum knee angle, total support time, step frequency, step length, pace, and stride length.

Discussion

Virtual reality is an innovative technology with broad applications, current and prospective. Immersive VR-assisted rehabilitation in patients with vivid treatment scenarios in the form of virtual games will stimulate patients’ interest through active participation. The feedback of VR games can also provide patients with performance awareness and effect feedback, which could be incentivizing. This study may reveal an improved method of stroke rehabilitation which can be helpful for clinical decision-making and future practice.

Background

Stroke is a serious disease with a high disability rate. Often occurring in elderly populations, stroke-related disability contributes one of the main causes of adult disability [1]. Studies show that stroke survivors experience residual physical dysfunction which has a great impact on their ability to live. Studies have reported that 55–80% of stroke survivors demonstrate continuous motor dysfunction, decreased quality of life, and limited activities in daily life [1,2,3,4]. Other studies have reported that 80% of stroke patients experience movement disorders, including loss of balance and gait ability [13]. The disease-related movement disorders and the subsequent decrease in daily living activity can be a great burden to patients, their families, and society. Gait disorder is one of the most common symptoms in stroke sequelae; thus, the recovery of walking ability is the key to improving patients’ self-care ability and quality of life. Compared with that of the healthy people, the gait of patients with cerebral apoplexy often manifests as slowed, shortened standing time on the paralyzed side, too early toes falling when standing, etc. [5]. As such, gait rehabilitation is often the primary goal of stroke rehabilitation [6,7,8]. As the population continues to age, an increasing number of stroke patients are posed to experience great challenges to disease-related effects. In turn, improving the efficiency of rehabilitation strategies remains of paramount importance.

Virtual reality (VR) is an innovative tool to realize connection, operation, and interaction between human vision and computer-simulated scenarios [9]. Non-immersive VR (for example Xbox Kinect) has been applied in clinical trials of stroke rehabilitation [1011]. VR training experience is interesting and enjoyable for the patient, which reduces fatigue, keeps patients in a happy mood, and reduces the boredom of repetitive, conventional rehabilitation. Non-immersive VR-assisted rehabilitation is proposed to provide a more personalized intervention therapy [12]. VR training for stroke patients can therefore improve the participation and autonomy of patients in the rehabilitation process, qualities that have been shown to be more cost and resource effective [13]. Overall, non-immersive VR has been shown to increase limb function learning and improves the quality of life [14].

Recently, immersive VR is a novel VR type. Immersive VR involves a head-mounted display with visual and auditory cues and controllers using haptic (sense of touch) feedback in a 3-dimensional environment [15]. Immersive VR is a technology that provides more realistic environment scene design and object tracking than previous ordinary VR [16], which provides virtual interaction and real-time feedback in vision, touch, hearing, and even motion in realistic scenarios. Patients can experience controllable movement or operation in a simulated virtual environment, so as to achieve the rebuilding or restoring of physical functions.

Immersive VR researches have been reported in the field of pain medicine [17]. In the field of post-stroke rehabilitation, immersive VR has also been reported in upper limb motor function and cognitive ability [1618]. However, a few studies have previously explored the application of immersive VR-assisted training in gait rehabilitation after stroke. For example, Biffi et al. found that immersive virtual reality platform enhances the walking ability of children with acquired brain injuries [19] and research by Irene Cortes-Perez has shown that immersive virtual reality improves balance in stroke patients and reduces the risk of falls [20]. Thus, research on immersive VR-assisted training in gait rehabilitation requires its own dedicated investigation. As a VR device of reasonable cost, it has become a powerful research tool for scientific researchers [2122]. This study will apply the immersive device to execute VR scenes of rehabilitation training according to clinical practice, so as to systematically evaluate the application of immersive VR technology in the rehabilitation of stroke gait disorders. […]

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Fig. 3 Virtual reality (VR) system and virtual scene. a A participant wears a virtual reality system. b A participant is carrying out crossbar training

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[ARTICLE] Adaptive Treadmill-Assisted Virtual Reality-Based Gait Rehabilitation for Post-Stroke Physical Reconditioning—a Feasibility Study in Low-Resource Settings – Full Text

Abstract

Objectives: Individuals with chronic stroke suffer from heterogeneous functional limitations, including cardiovascular dysfunction and gait disorders (associated with increased energy expenditure) besides psychological factors, e.g., motivation. To recondition their cardiovascular endurance and gait, rehabilitation exercises with gradually increasing exercise intensity suiting their individualized capabilities need to be offered. In principal accordance, here we (i) implemented an adaptive Virtual Reality (VR)-based treadmill-assisted platform sensitive to energy expenditure, (ii) investigated its safety and feasibility of use and (iii) examined the implications of gait exercise with this platform on cardiac and gait performance along with energy expenditure, clinical measures (to estimate physical reconditioning of subjects with stroke) and their views on community ambulation capabilities. Methods: Ten able-bodied subjects volunteered in a study to ensure its safety and feasibility of use. Nine subjects with chronic stroke underwent physical reconditioning over multiple exposures using our platform. We investigated the patients’ cardiac and gait performance prior and post exposure to our platform along with studying the clinical relevance of gait parameters in estimating their physical reconditioning. We collected the patients’ feedback. Results: We found statistical improvement in the gait parameters and reduction in energy expenditure during overground walk following ~1 month of gait exercise with our platform. They reported that the VR-based tasks were motivating. Conclusion: Results show that this platform can pave the way towards implementing home-based individualized exercise platform that can monitor one’s cardiac and gait performance capabilities while offering an adaptive and progressive gait exercise environment within safety thresholds suiting one’s exercise capabilities.

Physiological Cost Index sensitive Adaptive Response Technology (PCI-ART) for post-stroke physical reconditioning. Note: PCI- Physiological Cost Index; SST-Single Support Time; AL- Affected limb; UAL- Unaffected limb.

Physiological Cost Index sensitive Adaptive Response Technology (PCI-ART) for post-stroke physical reconditioning. Note: PCI- Physiological Cost Index; SST-Single Support Time; AL- Affected limb; UAL- Unaffected limb. 

SECTION I.

Introduction

Neurological disorders, such as stroke is a leading cause of disability with a prevalence rate of 424 in 100,000 individuals in India [1]. Often, these patients suffer from functional disabilities, heterogeneous physical deconditioning along with deteriorated cardiac functioning [2], [3] and a sedentary lifestyle immediately following stroke [4]. A deconditioned patient requires reconditioning of his/her cardiac capacity and ambulation capabilities that can be achieved through individualized rehabilitation [5]. This needs to be done under the supervision of a clinician who can monitor one’s functional capability, cardiac capacity and gait performance thereby recommending an appropriate dosage of the gait rehabilitation exercise intensity to the patient along with feedback. Such gait rehabilitation is crucial since about 80% of these patients have been reported to suffer from gait-related disorders [6] along with more energy expenditure than able-bodied individuals [7] often accompanied with reduced cardiac capacity [2], [4]. However, given the low doctor-to-patient ratio [8], lack of rehabilitation facilities and patients being released early from rehabilitation clinics followed by home-based exercise [9], particularly in developing countries like India, availing individualized rehabilitation services becomes difficult. Again, undergoing home-based exercises under clinician’s one-on-one supervision becomes difficult given the restricted healthcare resources, thereby limiting the rehabilitation outcomes [10]. Again, given the restricted healthcare resources, getting a clinician visiting the homes for delivering therapy sessions to patients is often costly causing the patients to miss the expert inputs on the exercise intensity suiting his/her exercise capability along with motivational feedback from the clinician [11]. This necessitates the use of a complementary technology-assisted rehabilitation platform that can be availed by the patient at his/her home [12] following a short stay at the rehabilitation clinic [13]. Again, it is preferred that this platform be capable of offering individualized gait exercise while varying the dosage of exercise intensity (based on the patient’s exercise capability) along with motivational feedback [14]. Additionally, exercise administered by this platform can be complemented with intermediate clinician-mediated assessments of rehabilitation outcomes, thereby reducing continuous demands on the restricted clinical resources. Thus, it is important to investigate the use of such technology-assisted gait exercise platforms that are capable of offering exercise based on one’s individualized capability along with motivational feedback.

Researchers have explored the use of technology-assisted solutions to offer rehabilitative gait exercises to these patients, along with presenting motivational feedback [15]–[16][17][18][19][20][21][22][23][24]. Specifically, investigators have used Virtual Reality (VR) coupled with a treadmill (having a limited footprint and making it suitable for home-based settings) while delivering individualized feedback [15] to the patient during exercise. Again, VR can help to project scenarios that can make the exercise engaging and interactive for a user [16]–[17][18][19]. In fact, Finley et al. have shown that the visual feedback offered by VR provides an optical flow that can induce changes in the gait performance (quantified in terms of gait parameters, e.g., Step Length, Step Symmetry, etc.) of such patients during treadmill-assisted walk [20]. Further, Jaffe et al. have reported positive implications of VR-based treadmill-assisted walking exercise on the gait performance of individuals with stroke [23], leading to improvement in their community ambulation [24]. These studies have shown the efficacy of the VR-based treadmill-assisted gait exercise platform to contribute towards gait rehabilitation of individuals suffering from stroke. Though promising, none of these platforms are sensitive to one’s individualized exercise capability and thus, in turn, could not decide an optimum dosage of exercise intensity suiting one’s capability, e.g., cardiac capacity and ambulation capability. This is particularly critical for individuals with stroke since they possess diminished exercise ability along with deteriorated cardiac functioning [2], [4].

From literature review, we find that after stroke, treadmill-assisted cardiac exercise programs can lead to one’s improved fitness and exercise capability [25]. For example, researchers have presented studies on Moderate-Intensity Continuous Exercise and High-Intensity Interval Training in which exercise protocols are individualized by a clinician based on one’s cardiac capacity while contributing to effective gait rehabilitation [26]–[27][28][29]. Though promising, these have not offered a progressive and adaptive exercise environment in which the dosage of exercise intensity is varied based on one’s cardiac capacity in real-time. Thus, the choice of optimum dosage of exercise intensity that can be individualized in real-time for a patient, still remains as inadequately explored [4]. For deciding the optimal dosage of rehabilitative exercise intensity, clinicians often refer to the guidelines recommended by the American College of Sports Medicine (ACSM) [30]. These guidelines suggest thresholds to decide the intensity of the exercise based on one’s metabolic energy consumption in terms of oxygen intake, heart rate, etc. Deciding the dosage of exercise intensity is crucial, particularly for individuals with stroke since their energy requirements have been reported to be 55-100% higher than that of their able-bodied counterparts [7]. Specifically, higher energy requirement often limits the capabilities of these patients and challenges their rehabilitation outcomes. This can be addressed if the technology-assisted gait exercise platform can offer individualized exercise (maintaining the safe exercise thresholds) based on the energy expenditure of the patients acquired in real-time during the exercise.

The energy expenditure can be defined as the cost of physical activity [4] and it is often expressed in terms of oxygen consumption or heart rate [31]. Thus, investigators have monitored the oxygen consumption and heart rate to estimate the energy expenditure of individuals with stroke during their walk [31], [32]. However, monitoring oxygen consumption during exercise requires a cumbersome setup [31], making it unsuitable for home-based rehabilitation. On the other hand, one’s heart rate (HR) can be monitored using portable solutions [33] that can be integrated with a treadmill in home-based settings. Researchers have explored treadmill-assisted gait exercise platforms that are sensitive to the user’s heart rate. For example, researchers have offered treadmill training to subjects with stroke in which some of them varied treadmill speed to achieve 45%-50% [34], while others varied speed to achieve 85% to 95% [35], [36] of one’s age-related maximum heart rate. Again, Pohl et al. have offered treadmill-assisted exercise to subjects with stroke while ensuring that the user’s heart rate settled to the respective resting-state heart rate [37]. Again of late, there had been advanced treadmills, available off-the-shelf, that can monitor one’s heart rate and vary the treadmill speed to maintain the user’s heart rate at a predefined level [38], [39]. Though one’s heart rate is an important indicator that needs to be considered during treadmill-assisted exercise, one’s walking speed while using the treadmill also offers important information on one’s exercise capability. This is because gait rehabilitation aims to improve one’s community ambulation that is related to one’s walking speed [40]. Thus, it would be interesting to explore the composite effect of one’s walking speed along with working and resting-state heart rates during treadmill-assisted gait exercise to study one’s energy expenditure, quantified in terms of a proxy index, namely Physiological Cost Index (PCI) [31].

Given that there are no existing studies that have used a treadmill-assisted gait exercise platform deciding the dosage of exercise intensity based on one’s PCI estimated in real-time during exercise, it might be interesting to explore the use of such an individualized gait exercise platform for individuals with stroke. Thus, we wanted to extend a treadmill-assisted gait exercise platform by making it adaptive to one’s individualized PCI. Additionally, we wanted to augment this platform with VR-based user interface to offer visual feedback to the user undergoing gait exercise. We hypothesized that such a gait exercise platform can recondition a patient’s exercise capability in terms of cardiac and gait performance to achieve improved community ambulation. The objectives of our research were three-fold, namely to (i) implement a novel PCI-sensitive Adaptive Response Technology (PCI-ART) offering VR-based treadmill-assisted gait exercise, (ii) investigate the safety and feasibility of use of this platform among able-bodied individuals before applying it to subjects with stroke and (iii) examine implications of undergoing gait exercise with this platform on the patients’ (a) cardiac and gait performance along with energy expenditure, (b) clinical measures estimating the physical reconditioning and (c) views on their community ambulation capabilities.

The rest of the paper is organized as follows: Section II presents our system design. Section III explains the experiments and procedures of this study. Section IV discusses the results. In Section V, we summarize our findings, limitations, and scope of future research.[…]

Continue —-> Adaptive Treadmill-Assisted Virtual Reality-Based Gait Rehabilitation for Post-Stroke Physical Reconditioning—a Feasibility Study in Low-Resource Settings – IEEE Journals & Magazine

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[Abstract + References] Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions

Abstract

The recovery of walking capacity is one of the main aims in stroke rehabilitation. Being able to predict if and when a patient is going to walk after stroke is of major interest in terms of management of the patients and their family’s expectations and in terms of discharge destination and timing previsions. This article reviews the recent literature regarding the predictive factors for gait recovery and the best recommendations in terms of gait rehabilitation in stroke patients. Trunk control and lower limb motor control (e.g. hip extensor muscle force) seem to be the best predictors of gait recovery as shown by the TWIST algorithm, which is a simple tool that can be applied in clinical practice at 1 week post-stroke. In terms of walking performance, the 6-min walking test is the best predictor of community ambulation. Various techniques are available for gait rehabilitation, including treadmill training with or without body weight support, robotic-assisted therapy, virtual reality, circuit class training and self-rehabilitation programmes. These techniques should be applied at specific timing during post-stroke rehabilitation, according to patient’s functional status.

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[Abstract] Enriching footsteps sounds in gait rehabilitation in chronic stroke patients: a pilot study

Abstract

In the context of neurorehabilitation, sound is being increasingly applied for facilitating sensorimotor learning. In this study, we aimed to test the potential value of auditory stimulation for improving gait in chronic stroke patients by inducing alterations of the frequency spectra of walking sounds via a sound system that selectively amplifies and equalizes the signal in order to produce distorted auditory feedback. Twenty‐two patients with lower extremity paresis were exposed to real‐time alterations of their footstep sounds while walking. Changes in body perception, emotion, and gait were quantified. Our results suggest that by altering footsteps sounds, several gait parameters can be modified in terms of left–right foot asymmetry. We observed that augmenting low‐frequency bands or amplifying the natural walking sounds led to a reduction in the asymmetry index of stance and stride times, whereas it inverted the asymmetry pattern in heel–ground exerted force. By contrast, augmenting high‐frequency bands led to opposite results. These gait changes might be related to updating of internal forward models, signaling the need for adjustment of the motor system to reduce the perceived discrepancies between predicted–actual sensory feedbacks. Our findings may have the potential to enhance gait awareness in stroke patients and other clinical conditions, supporting gait rehabilitation.

 

via Enriching footsteps sounds in gait rehabilitation in chronic stroke patients: a pilot study – Gomez‐Andres – – Annals of the New York Academy of Sciences – Wiley Online Library

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[ARTICLE] State-of-the-art research in robotic hip exoskeletons: A general review – Full Text

Abstract

Ageing population is now a global challenge, where physical deterioration is the common feature in elderly people. In addition, the diseases, such as spinal cord injury, stroke, and injury, could cause a partial or total loss of the ability of human locomotion. Thus, assistance is necessary for them to perform safe activities of daily living. Robotic hip exoskeletons are able to support ambulatory functions in elderly people and provide rehabilitation for the patients with gait impairments. They can also augment human performance during normal walking, loaded walking, and manual handling of heavy-duty tasks by providing assistive force/torque. In this article, a systematic review of robotic hip exoskeletons is presented, where biomechanics of the human hip joint, pathological gait pattern, and common approaches to the design of robotic hip exoskeletons are described. Finally, limitations of the available robotic hip exoskeletons and their possible future directions are discussed, which could serve a useful reference for the engineers and researchers to develop robotic hip exoskeletons with practical and plausible applications in geriatric orthopaedics.

Introduction

Most countries are reported with rising life expectancy and therefore a rapid increase in ageing population worldwide. Elderly people normally have physical deterioration and frailty, which imposes a heavy burden on the social health care system. The decreased physical capabilities owing to deterioration of neuromusculoskeletal system makes elderly people walking with a changed gait pattern and more cautious [1]. They generally have increased step variability and metabolic cost of walking, lower walking speed, shorter step-length, and reduced range of motion of the ankle, knee, and hip joints [2,3]. In addition, the elderly people have difficulties in maintaining trunk stability and have a risk of falls [4]. The lower limbs dysfunction and gait impairments are also common in elderly people, which could cause unnatural gait patterns [5,6]. Nearly three-quarters of all strokes occur in people over the age of 65 years. All those could reduce the mobility of elderly people and lead them to fewer independent lives and poor quality of life.

In addition, the patients with neurological disorders caused by diseases or injuries such as a stroke and spinal cord injury generally have muscle weakness, which could lead to insufficient force/torque at the hip joints during human locomotion [7]. These individuals often have decreased capacities of self-balancing and increased falling risk [8]. Therefore, approaches that can help elderly people and these patients to maintain a good walking pattern are desirable [9]. The past decade has witnessed a remarkable progress in research and development (R&D) of wearable medical devices for the patients with gait impairments [10]. The use of wearable medical devices such as robotic exoskeletons [11] and active orthoses [12] have become one of the most promising approaches to assist the individuals with gait disorders. It is predicted by a researcher that robotic exoskeletons would be commonly used in the community by 2024 [13].

Robotic hip exoskeletons integrate the robot power and human intelligence, and they can provide controllable assistive force/torque at the wearers’ hip joints with an anthropomorphic configuration. One application of robotic hip exoskeletons is on gait rehabilitation. They are able to train the wearers’ muscles and assist their movements for therapeutic exercise. The robot-assisted rehabilitation can release therapists from the heavy burden of rehabilitation training and provide long training sessions for the patients with good consistency. Human regular walking is able to reduce the risk of strokes and coronary heart disease, and hence to improve the physical and mental health [14]. Thus, it is promising to make human walking more efficient. Human effort is related to metabolic expenditure, and the other application of robotic hip exoskeletons is to augment human performance such as increasing the human strength and endurance.

By comparing with the human ankle joint, the hip joint needs higher metabolic cost for the generation of similar mechanical joint power owing to the differences in muscle characteristics [15]. Therefore, in addition to the robotic ankle exoskeletons developed for metabolic benefit [16], the hip joint actuating is also a promising strategy because large positive torque is provided by the human hip during the activities of daily living [17]. Robotic hip exoskeletons also have the potential to integrate into the factories. In warehouses and manufacturing environments, the workers often have to handle heavy goods, which could load their lumbar spine and increase the risk of physical injury such as low back pain and other work-related musculoskeletal disorders [18,19]. The work-related injuries could have a serious impact on the quality of life of these individuals. Robotic hip exoskeletons are able to assist these workers during manual handling of heavy-duty tasks.

The aim of this article is to review the aspects of engineering design and control strategies of robotic hip exoskeletons for the two applications, i.e., gait rehabilitation and human performance augmentation, and to discuss some possible future directions to improve the currently available robotic hip exoskeletons. We hope this review would provide useful information for the engineers and researchers to design desirable robotic hip exoskeletons, especially for those new to this field and would like to make contributions to this important multidisciplinary biomedical engineering and orthopaedic rehabilitation filed.

In this article, the biomechanics of the human hip joint and pathological gait of individuals with hip dysfunction are first presented before reviewing the mechanical structure, actuators, sensors, and control strategies of the existing robotic hip exoskeletons. Finally, this article discusses the limitations of the available robotic hip exoskeletons and their possible R&D directions with respect to clinical applications.

Biomechanics of human hip and pathological gait

To increase adaptability and achieve minimal interference, bioinspired design of robotic hip exoskeletons is required. This section presents a brief description of biomechanics of the human hip joint and the pathological gait pattern of individuals with hip dysfunction, which provides a basis for the design and control of robotic hip exoskeletons.

Biomechanics of normal human hip joint

The human hip joint is a ball-and-socket joint and joins the pelvis to the femur. It is composed of the cup-shaped acetabulum and femoral head, which are connected and supported by several tissues and muscles [20,21]. In human locomotion analysis, the human hip behaves as a spherical joint with three degrees of freedom (DOFs), i.e., flexion/extension, abduction/adduction, and internal/external rotation. A human gait cycle is defined as a sequence of movements during walking and is basically composed of the alternating stance phase and swing phase [22], as shown in Fig. 1. According to the gait analysis of people with a normal gait pattern [23], the human hip joint will generate positive work to bear the body weight, propel the body forward, and stabilize the trunk during the period of 0–35% of a gait cycle. After this phase, the hip joint angle will cross the zero degree and the leg will become vertical.

Fig. 1

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Fig. 1. Normal gait cycle. The green lines represent the right leg, and the blue lines represent the left leg. The gait cycle is composed of the alternating stance phase and swing phase, and it starts when one foot contacts the ground and ends when the same foot contacts the ground again.

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[Abstract + References] A Wireless BCI-FES Based on Motor Intent for Lower Limb Rehabilitation

Abstract

Recent investigations have proposed brain computer interfaces combined with functional electrical stimulation as a novel approach for upper limb motor recovery. These systems could detect motor intention movement as a power decrease of the sensorimotor rhythms in the electroencephalography signal, even in people with damaged brain cortex. However, these systems use a large number of electrodes and wired communication to be employed for gait rehabilitation. In this paper, the design and development of a wireless brain computer interface combined with functional electrical stimulation aimed at lower limb motor recovery is presented. The design requirements also account the dynamic of a rehabilitation therapy by allowing the therapist to adapt the system during the session. A preliminary evaluation of the system in a subject with right lower limb motor impairment due to multiple sclerosis was conducted and as a performance metric, the true positive rate was computed. The developed system evidenced a robust wireless communication and was able to detect lower limb motor intention. The mean of the performance metric was 75%. The results encouraged the possibility of testing the developed system in a gait rehabilitation clinical study.

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[Abstract] A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke

Background. Gait impairments after stroke arise from dysfunction of one or several features of the walking pattern. Traditional rehabilitation practice focuses on improving one component at a time, which may leave certain features unaddressed or prolong rehabilitation time. Recent work shows that neurologically intact adults can learn multiple movement components simultaneously.

Objective. To determine whether a dual-learning paradigm, incorporating 2 distinct motor tasks, can simultaneously improve 2 impaired components of the gait pattern in people posttroke.

Methods. Twelve individuals with stroke participated. Participants completed 2 sessions during which they received visual feedback reflecting paretic knee flexion during walking. During the learning phase of the experiment, an unseen offset was applied to this feedback, promoting increased paretic knee flexion. During the first session, this task was performed while walking on a split-belt treadmill intended to improve step length asymmetry. During the second session, it was performed during tied-belt walking.

Results. The dual-learning task simultaneously increased paretic knee flexion and decreased step length asymmetry in the majority of people post-stroke. Split-belt treadmill walking did not significantly interfere with joint-angle learning: participants had similar rates and magnitudes of joint-angle learning during both single and dual-learning conditions. Participants also had significant changes in the amount of paretic hip flexion in both single and dual-learning conditions.

Conclusions. People with stroke can perform a dual-learning paradigm and change 2 clinically relevant gait impairments in a single session. Long-term studies are needed to determine if this strategy can be used to efficiently and permanently alter multiple gait impairments.

via A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke – Kendra M. Cherry-Allen, Matthew A. Statton, Pablo A. Celnik, Amy J. Bastian, 2018

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[Abstract] A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke

Background. Gait impairments after stroke arise from dysfunction of one or several features of the walking pattern. Traditional rehabilitation practice focuses on improving one component at a time, which may leave certain features unaddressed or prolong rehabilitation time. Recent work shows that neurologically intact adults can learn multiple movement components simultaneously.

Objective. To determine whether a dual-learning paradigm, incorporating 2 distinct motor tasks, can simultaneously improve 2 impaired components of the gait pattern in people posttroke.

Methods. Twelve individuals with stroke participated. Participants completed 2 sessions during which they received visual feedback reflecting paretic knee flexion during walking. During the learning phase of the experiment, an unseen offset was applied to this feedback, promoting increased paretic knee flexion. During the first session, this task was performed while walking on a split-belt treadmill intended to improve step length asymmetry. During the second session, it was performed during tied-belt walking.

Results. The dual-learning task simultaneously increased paretic knee flexion and decreased step length asymmetry in the majority of people post-stroke. Split-belt treadmill walking did not significantly interfere with joint-angle learning: participants had similar rates and magnitudes of joint-angle learning during both single and dual-learning conditions. Participants also had significant changes in the amount of paretic hip flexion in both single and dual-learning conditions.

Conclusions. People with stroke can perform a dual-learning paradigm and change 2 clinically relevant gait impairments in a single session. Long-term studies are needed to determine if this strategy can be used to efficiently and permanently alter multiple gait impairments.

via A Dual-Learning Paradigm Simultaneously Improves Multiple Features of Gait Post-Stroke – Kendra M. Cherry-Allen, Matthew A. Statton, Pablo A. Celnik, Amy J. Bastian, 2018

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