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Introduction: Physical inactivity and sedentary behavior both increase the risk of chronic disease and mortality. Regular participation in physical activity and reducing sedentary behavior play important roles in maintaining physical health and disease prevention. Objective: The purpose of this study was to investigate the effect of programed walking exercise using a wearable hip exoskeleton, Bot Fit on muscle strength, muscle effort, and the kinematics of the pelvis in younger adults. Methods: We designed three parallel experimental conditions and randomly assigned participants to one of three groups: those assigned to exercise using an interval program of Bot Fit (interval group), those who used a power program of Bot Fit (power group), and a control group who exercised without Bot Fit. A total of 45 young adults participated in 18 exercise-intervention sessions over six weeks, and all participants were assessed at two time points: before and after the 18 exercise sessions. Each assessment evaluated muscle strength, muscle effort, and the kinematics of the pelvis during walking. In addition, the number of steps, distance, energy expenditure, and heart rate for 30 min during the exercise sessions were recorded. Results: A significant increase in the maximum voluntary contraction (MVC) of the left biceps femoris (BF) was evident in the interval group, while significant changes in the MVC of the bilateral BF were seen in the power group after Bot Fit exercise. A significant decrease of muscle effort in the right BF in the interval group and right lumbar erector spinae and bilateral BF in the power group were also observed. In addition, the symmetry index of pelvic tilt significantly improved in the interval group, and greater exercise volume and intensity in both the interval and power groups compared with the control group were confirmed as measured by the number of steps, distance, energy expenditure, and heart rate. Conclusions: The results of this study confirmed the beneficial effect of programed walking exercise using the Bot Fit on muscle strength of trunk and lower extremities, muscle effort, and pelvic movement symmetry in younger adults. Personalized exercise programs can be provided for younger adults using various resistance or assistance modes of robotic device with the Bot Fit. Trial Registration: ClinicalTrials.gov, NCT05862077. Registered 22 March 2022, https://register.clinicaltrials.gov/. Key Points: • Bot Fit exercise offers several key advantages over exercise without a Bot Fit in terms of muscle strength, muscle effort, and pelvic symmetry during walking in younger adults. • Greater exercise volume and intensity in interval and power groups who exercised with Bot Fit were confirmed through number of steps, distance, energy expenditure, and heart rate compared to control group who exercised without Bot Fit. [ABSTRACT FROM AUTHOR]

Abstract Introduction Physical inactivity and sedentary behavior both increase the risk of chronic disease and mortality. Regular participation in physical activity and reducing sedentary behavior play important roles in maintaining physical health and disease prevention. Objective The purpose of this study was to investigate the effect of programed walking exercise using a wearable hip exoskeleton, Bot Fit on muscle strength, muscle effort, and the kinematics of the pelvis in younger adults. Methods We designed three parallel experimental conditions and randomly assigned participants to one of three groups: those assigned to exercise using an interval program of Bot Fit (interval group), those who used a power program of Bot Fit (power group), and a control group who exercised without Bot Fit. A total of 45 young adults participated in 18 exercise-intervention sessions over six weeks, and all participants were assessed at two time points: before and after the 18 exercise sessions. Each assessment evaluated muscle strength, muscle effort, and the kinematics of the pelvis during walking. In addition, the number of steps, distance, energy expenditure, and heart rate for 30 min during the exercise sessions were recorded. Results A significant increase in the maximum voluntary contraction (MVC) of the left biceps femoris (BF) was evident in the interval group, while significant changes in the MVC of the bilateral BF were seen in the power group after Bot Fit exercise. A significant decrease of muscle effort in the right BF in the interval group and right lumbar erector spinae and bilateral BF in the power group were also observed. In addition, the symmetry index of pelvic tilt significantly improved in the interval group, and greater exercise volume and intensity in both the interval and power groups compared with the control group were confirmed as measured by the number of steps, distance, energy expenditure, and heart rate. Conclusions The results of this study confirmed the beneficial effect of programed walking exercise using the Bot Fit on muscle strength of trunk and lower extremities, muscle effort, and pelvic movement symmetry in younger adults. Personalized exercise programs can be provided for younger adults using various resistance or assistance modes of robotic device with the Bot Fit. Trial Registration ClinicalTrials.gov, NCT05862077. Registered 22 March 2022, https://register.clinicaltrials.gov/ .

Background Gait disturbances are prevalent and debilitating symptoms, diminishing mobility and quality of life for Parkinson's disease (PD) individuals. While traditional treatments offer partial relief, there is a growing interest in alternative interventions to address this challenge. Recently, a remarkable surge in assisted technology (AT) development was witnessed to aid individuals with PD.

Activity-based Training (ABT) represents the current standard of neurological rehabilitation. Robotic Locomotor Training (RLT), an innovative technique, aims to enhance rehabilitation outcomes. This study aimed to conduct a randomized pilot and feasibility trial of a locomotor training program within South Africa. Individuals with chronic traumatic motor incomplete tetraplegia (n = 16). Each intervention involved 60-minute sessions, 3x per week, for 24-weeks. Outcomes included feasibility measures and functional capacity. 17 out of 110 individuals initiated the program (recruitment rate = 15.4%) and 16 completed the program (drop-out rate = 5.8%) and attended sessions (attendance rate = 93.9%). Both groups showed a significant increase in upper extremity motor score (MS) and abdominal strength post intervention. Only the RLT group showed a significant change in lower extremity MS, with a mean increase of 3.00 [0.00; 16.5] points over time. Distance walked in the Functional Ambulatory Inventory (SCI-FAI) increased significantly (p = 0.02) over time only for the RLT group. Feasibility rates of the intervention and functional outcomes justify a subsequent powered RCT comparing RLT to ABT as an effective rehabilitation tool for potentially improving functional strength and walking capacity in people with incomplete SCI. Spinal cord injury causes severe limitations to functional capacity, independence, and quality of life. Robotic Locomotor Training is growing rehabilitation modality for people with spinal cord injury, but currently its effects on functional capacity are limited. In a relatively small sample, this study shows that large, randomized control trials are feasible within a low-income setting. The preliminary findings of this study show that 12 weeks of locomotor training can improve ambulatory function and functional strength in individuals with spinal cord injury. [ABSTRACT FROM AUTHOR]

Systematically determine the effectiveness and users' perceptions of upper extremity (UE) exoskeletons and robot-assisted devices for pediatric rehabilitation. PubMed/Medline, Web of Science, Scopus, and Cochrane Library were searched for studies with "exoskeletons"/"robot-assisted devices", children with disabilities, effectiveness data, and English publication. Intervention effectiveness outcomes were classified within components of the International Classification of Functioning, Disability, and Health, Children and Youth Version (ICF-CY). Secondary data (users' perceptions; implementation setting) were extracted. Risk of bias and methodological quality were assessed. Descriptive analyses were performed. Seventy-two articles were included. Most evaluated body structure and function and activity outcomes with less emphasis on participation. Most effects across all ICF-CY levels were positive. Devices were primarily evaluated in clinical or laboratory rather than natural environments. Perceptions about device effectiveness were mostly positive, while those about expression, accessibility, and esthetics were mostly negative. A need for increased rigor in research study design was detected. Across populations, devices, settings, interventions, and dosing schedules, UE exoskeletons and robot-assisted devices may improve function, activity, and perhaps participation for children with physical disabilities. Future work should transition devices into natural environments, design devices and implementation strategies to address users' negative perceptions, and increase research rigor. [ABSTRACT FROM AUTHOR]

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 mostmentioned Consolidated Framework for Implementation Research constructswere 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. [ABSTRACT FROM AUTHOR]

After spinal cord injury (SCI), inpatient rehabilitation begins and continues through outpatient therapy. Overground exoskeleton gait training (OEGT) has been shown to be feasible in both settings, yet its use as an intervention across the continuum has not yet been reported. This study describes OEGT for patients with SCI across the continuum and its effects on clinical outcomes. Medical records of patients with SCI who completed at least one OEGT session during inpatient and outpatient rehabilitation from 2018 to 2021 were retrospectively reviewed. Demographic data, Walking Index for Spinal Cord Injury-II (WISCI-II) scores, and OEGT session details (frequency, "walk" time, "up" time, and step count) were extracted. Eighteen patients [male (83%), White (61%), aged 37.4 ± 15 years, with tetraplegia (50%), American Spinal Injury Association Impairment Scale A (28%), B (22%), C (39%), D (11%)] completed OEGT sessions (motor complete, 18.2 ± 10.3; motor incomplete, 16.7 ± 7.7) over approximately 18 weeks (motor complete, 15.1 ± 6.4; motor incomplete, 19.0 ± 8.2). Patients demonstrated improved OEGT session tolerance on device metrics including "walk" time (motor complete, 7:51 ± 4:42 to 24:50 ± 9:35 minutes; motor incomplete, 12:16 ± 6:01 to 20:01 ± 08:05 minutes), "up" time (motor complete, 16:03 ± 7:41 to 29:49 ± 12:44 minutes; motor incomplete, 16:38 ± 4:51 to 23:06 ± 08:50 minutes), and step count (motor complete, 340 ± 295.9 to 840.2 ± 379.4; motor incomplete, 372.3 ± 225.2 to 713.2 ± 272). Across therapy settings, patients with motor complete SCI experienced improvement in WISCI-II scores from 0 ± 0 at inpatient admission to 3 ± 4.6 by outpatient discharge, whereas the motor incomplete group demonstrated a change of 0.2 ± 0.4 to 9.0 ± 6.4. Patients completed OEGT across the therapy continuum. Patients with motor incomplete SCI experienced clinically meaningful improvements in walking function. [ABSTRACT FROM AUTHOR]

Exoskeletons and exosuits (collectively termed EXOs) have the potential to reduce the risk of work-related musculoskeletal disorders (WMSDs) by protecting workers from exertion and muscle fatigue due to physically demanding, repetitive, and prolonged work in construction workplaces. However, the use of EXOs in construction is in its infancy, and much of the knowledge required to drive the acceptance, adoption, and application of this technology is still lacking. The objective of this research is to identify the facilitators, barriers, and corresponding solutions to foster the adoption of EXOs in construction workplaces through a sequential, multistage Delphi approach. Eighteen experts from academia, industry, and government gathered in a workshop to provide insights and exchange opinions regarding facilitators, barriers, and potential solutions from a holistic perspective with respect to business, technology, organization, policy/regulation, ergonomics/safety, and end users (construction-trade professionals). Consensus was reached regarding all these perspectives, including top barriers and potential solution strategies. The outcomes of this study will help the community gain a comprehensive understanding of the potential for EXO use in the construction industry, which may enable the development of a viable roadmap for the evolution of EXO technology and the future of EXO-enabled workers and work in construction workplaces.

BackgroundAutonomous exoskeletons will need to be useful at a variety of walking speeds, but it is unclear how optimal hip-knee-ankle exoskeleton assistance should change with speed. Biological joint moments tend to increase with speed, and in some cases, optimized ankle exoskeleton torques follow a similar trend. Ideal hip-knee-ankle exoskeleton torque may also increase with speed. The purpose of this study was to characterize the relationship between walking speed, optimal hip-knee-ankle exoskeleton assistance, and the benefits to metabolic energy cost.MethodsWe optimized hip-knee-ankle exoskeleton assistance to reduce metabolic cost for three able-bodied participants walking at 1.0 m/s, 1.25 m/s and 1.5 m/s. We measured metabolic cost, muscle activity, exoskeleton assistance and kinematics. We performed Friedman's tests to analyze trends across walking speeds and paired t-tests to determine if changes from the unassisted conditions to the assisted conditions were significant.ResultsExoskeleton assistance reduced the metabolic cost of walking compared to wearing the exoskeleton with no torque applied by 26%, 47% and 50% at 1.0, 1.25 and 1.5 m/s, respectively. For all three participants, optimized exoskeleton ankle torque was the smallest for slow walking, while hip and knee torque changed slightly with speed in ways that varied across participants. Total applied positive power increased with speed for all three participants, largely due to increased joint velocities, which consistently increased with speed.ConclusionsExoskeleton assistance is effective at a range of speeds and is most effective at medium and fast walking speeds. Exoskeleton assistance was less effective for slow walking, which may explain the limited success in reducing metabolic cost for patient populations through exoskeleton assistance. Exoskeleton designers may have more success when targeting activities and groups with faster walking speeds. Speed-related changes in optimized exoskeleton assistance varied by participant, indicating either the benefit of participant-specific tuning or that a wide variety of torque profiles are similarly effective.

Hand-function recovery is often a goal for stroke survivors undergoing therapy. This work aimed to design, build, and verify a pneumatic hand training device for its eventual use in post-stroke rehabilitation. The system was built considering prior research in the field of robotic hand rehabilitation as well as specifications and design constraints developed with physiotherapists. The system contained pneumatic airbag actuators for the fingers and thumb of the hand, a set of flex, pressure, and flow sensors, and software and hardware controls. An experiment with the system was carried out on 30 healthy individuals. The sensor readings were analyzed for repeatability and reliability. Position sensors and an approximate biomechanical model of the index finger were used to estimate joint angles during operation. A survey was also issued to the users to evaluate their comfort levels with the device. It was found that the system was safe and comfortable when moving the fingers of the hand into an extension. [ABSTRACT FROM AUTHOR]

In recent decades, extensive attention has been paid to the study and development of robotic devices specifically designed for hand rehabilitation. Accordingly, a many concepts concerning rigid, soft, and hybrid types have emerged in the literature, with significant ongoing activity being directed towards the development of new solutions. In this context, the paper focuses on the technical features of devices conceived for the robotic rehabilitation of the hand with reference to the three kinds of exoskeleton architecture and the clinical requirements demanded by the target impairment of the end-user. The work proposes a roadmap (i) for both the design and selection of exoskeletons for hand rehabilitation, (ii) to discriminate among the peculiarities of soft, rigid, and hybrid devices, and (iii) with an impairment-oriented rationale. The clinical requirements expected for an exoskeleton are identified by applying a PICO-inspired approach focused on the impairment analysis; the technical features are extracted from a proposed design process for exoskeletons combined with a narrative literature review. A cross-analysis between device families and features is presented to provide a supporting tool for both the design and selection of exoskeletons according to an impairment-oriented rationale. [ABSTRACT FROM AUTHOR]

BackgroundPowered hand exoskeletons are an emerging technology that have shown promise in assisting individuals with impaired hand function. A number of hand exoskeleton designs have been described in the literature; however, the majority have not been supported by patient-oriented criteria.ObjectiveThe aim of this study was to define preliminary end-user needs and expectations for an assistive hand exoskeleton.Study designExplorative interview and case series.MethodsSix clinicians and eight individuals with impaired hand function were interviewed in small groups or individually. A standardized list of questions was used to elicit feedback on specific design criteria or promote the discovery of new criteria. In addition, three participants with impaired hand function returned for a second session where hand characteristics, such as range of motion and force required to flex/extend fingers, were recorded to further quantify design requirements.ResultsInterview responses indicated that there was general consensus among participants on criteria relating to important grasp patterns, grip strength, wear time, and acceptable bulk/weight. However, interview responses and hand characteristics also revealed important differences between individuals with impaired hand function.ConclusionQualitative and quantitative data were collected to develop an understanding of end-user design requirements for assistive hand exoskeletons. Although the data collected were helpful in identifying some preliminary criteria, differences between participants exist and identifying a universal set of criteria applicable across individuals with impaired hand function is challenging. This work reinforces the importance of involving users of rehabilitation technology in the device development process.

Rehabilitation robots have shown promise in improving the gait of children with childhood-onset motor disabilities. This study aimed to investigate the long-term benefits of training using a wearable Hybrid Assistive Limb (HAL) in these patients. Training using a HAL was performed for 20 min a day, two to four times a week, over four weeks (12 sessions in total). The Gross Motor Function Measure (GMFM) was the primary outcome measure, and the secondary outcome measures were gait speed, step length, cadence, 6-min walking distance (6MD), Pediatric Evaluation of Disability Inventory, and Canadian Occupational Performance Measure (COPM). Patients underwent assessments before the intervention, immediately after the intervention, and at 1-, 2-, 3-month and 1-year follow-ups. Nine participants (five males, four females; mean age: 18.9 years) with cerebral palsy (n = 7), critical illness polyneuropathy (n = 1), and encephalitis (n = 1) were enrolled. After training using HAL, GMFM, gait speed, cadence, 6MD, and COPM significantly improved (all p < 0.05). Improvements in GMFM were maintained one year after the intervention (p < 0.001) and in self-selected gait speed and 6MD three months after the intervention (p < 0.05). Training using HAL may be safe and feasible for childhood-onset motor disabilities and may maintain long-term improvements in motor function and walking ability.

The preliminary test results of a novel robotic hand rehabilitation device aimed at treatment for the loss of motor abilities in the fingers and thumb due to stroke are presented. This device has been developed in collaboration with physiotherapists who regularly treat individuals who have suffered from a stroke. The device was tested on healthy adults to ensure comfort, user accessibility, and repeatability for various hand sizes in preparation for obtaining permission from regulatory bodies and implementing the design in a full clinical trial. Trials were conducted with 52 healthy individuals ranging in age from 19 to 93 with an average age of 58. A comfort survey and force data ANOVA were performed to measure hand motions and ensure the repeatability and accessibility of the system. Readings from the force sensor (p < 0.05) showed no significant difference between repetitions for each participant. All subjects considered the device comfortable. The device scored a mean comfort value of 8.5/10 on all comfort surveys and received the approval of all physiotherapists involved. The device has satisfied all design specifications, and the positive results of the participants suggest that it can be considered safe and reliable. It can therefore be moved forward for clinical trials with post-stroke users. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of a robotic exoskeleton is to match the torque and angular profile of a healthy human subject in performing activities of daily living. Power and mass are the main requirements considered in the robotic exoskeletons that need to be reduced so that portable designs to perform independent activities by the elderly users could be adopted. OBJECTIVE: This paper evaluates a systematic approach for the design optimization strategies of elastic elements and implements an actuator design solution for an ideal combination of components of an elastic actuation system while providing the same level of support to the elderly. METHODS: A multi-factor optimization technique was used to determine the optimum stiffness and engagement angle of the spring within its elastic limits at the hip, knee and ankle joints. An actuator design framework was developed for the elderly users to match the torque-angle characteristics of the healthy human with the best motor and transmission system combined with series or parallel elasticity in an elastic actuator. RESULTS: With the optimized spring stiffness, a parallel elastic element significantly reduced the torque and power requirements up to 90% for some manoeuvres for the users to perform ADL. When compared with the rigid actuation system, the optimized robotic exoskeleton actuation system reduced the power consumption of up to 52% using elastic elements. CONCLUSION: A lightweight, smaller design of an elastic actuation system consuming less power as compared to a rigid system was realized using this approach. This will help to reduce the battery size and hence the portability of the system could be better adopted to support elderly users in performing daily living activities. It was established that parallel elastic actuators (PEA) can reduce the torque and power better than series elastic actuators (SEA) in performing everyday tasks for the elderly. [ABSTRACT FROM AUTHOR]

With the booming development of rehabilitation medicine engineering in recent years, the role of lower limb exoskeletal robotic systems in the treatment of walking function recovery of post⁃stroke has received much attention. This paper intends to classify and summarize the lower limb exoskeletal robotic systems used for walking function recovery at different periods of stroke, summarize the mechanism of improving walking function, and review the impact of lower limb exoskeletal robotic systems on the walking function of stroke patients at different periods, current challenges and future development direction, in order to promote the clinical application of lower limb exoskeletal robotic systems.

Abstract Background Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort. Methods A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and therapy costs. We estimate cost-effectiveness using the incremental cost utility ratio and present results on the cost-effectiveness plane and on cost-effectiveness acceptability curves. Results Participants in the prospective, practice-based cohort with complete EQ-5D data (n = 99) qualified for the analysis. Both conventional training and overground robotic training experienced an improvement in QALYs. Only people with incomplete SCI improved with conventional locomotor training, 0.045 (SD 0.28), and only people with complete SCI improved with overground robotic training, 0.097 (SD 0.20). Costs were lower for conventional training, $1758 (SD $1697) versus overground robotic training $3952 (SD $3989), and lower for those with incomplete versus complete injury. Conventional overground training was more effective and cost less than robotic therapy for people with incomplete SCI. Overground robotic training was more effective and cost more than conventional training for people with complete SCI. The incremental cost utility ratio for overground robotic training for people with complete spinal cord injury was $12,353/QALY. Conclusions The most cost-effective locomotor training strategy for people with SCI differed based on injury completeness. Conventional training was more cost-effective than overground robotic training for people with incomplete SCI. Overground robotic training was more cost-effective than conventional training for people with complete SCI. The effect estimates may be subject to limitations associated with small sample sizes and practice-based evidence methodology. These estimates provide a baseline for future research.

In this study, we aimed to evaluate the short-term outcomes of a rehabilitation program with the Hybrid Assistive Limb® after soft tissue lengthening in young patients with cerebral palsy. We assessed six patients with cerebral palsy who underwent soft tissue surgery followed by gait training using the Hybrid Assistive Limb®. Clinical assessments were conducted preoperatively, before, immediately after, and at 1, 2, and 3 months after gait training. Gross Motor Function Measure was improved 5.93 ± 6.11% (mean ± standard deviation, p < 0.05), Canadian Occupational Performance Measure performance was improved 3.12 ± 1.53 points, and satisfaction was improved 3.80 ± 2.14 points (p < 0.05). The knee extension strength on the operated side was changed 7.75 ± 4.97 Nm after the intervention (p = 0.07). In ambulatory patients, gait speed was changed 8.37 ± 1.72 m/min, stride length was changed 10 ± 6.16 cm, and 6 min walking distance was changed 52 ± 16 m after the intervention. Training with the Hybrid Assistive Limb® may improve walking ability and clinical outcomes in young patients with cerebral palsy after soft tissue lengthening.

Abstract Exoskeletons are externally worn motorized devices that assist with sit-to-stand and walking in individuals with motor and functional impairments. The Food & Drug Administration (FDA) has approved several of these technologies for clinical use however, there is limited evidence to guide optimal utilization in every day clinical practice. With the diversity of technologies & equipment available, it presents a challenge for clinicians to decide which device to use, when to initiate, how to implement these technologies with different patient presentations, and when to wean off the devices. Thus, we present a clinical utilization framework specific to exoskeletons with four aims. These aims are to assist with clinical decision making of when exoskeleton use is clinically indicated, identification of which device is most appropriate based on patient deficits and device characteristics, providing guidance on dosage parameters within a plan of care and guidance for reflection following utilization. This framework streamlines how clinicians can approach implementation through the synthesis of published evidence with appropriate clinical assessment & device selection to reflection for success and understanding of these innovative & complex technologies.

Abstract Background High-intensity repetitive task-specific practice might be the most effective strategy to promote motor recovery after stroke, and electromechanical-assisted gait training represents one of the treatment options. However, there is still difficulty in clarifying the difference between conventional gait training and electromechanically assisted gait training. Methods The study is a multicenter, randomized, parallel-group clinical trial for stroke patients. Three clinical research centers in Korea (Dongguk University Ilsan Hospital, Chungnam National University Hospital, and Seoul National University Bundang Hospital) will participate in the clinical trial and 144 stroke patients will be registered. Enrolled patients are assigned to two groups, an experimental group and a control group, according to a randomization table. In addition, patients are treated for half an hour (one session) five times a week for 4 weeks. Both groups carry out basic rehabilitation (central nervous system development therapy and strength exercise) and the experimental group executes robotic walking rehabilitation treatment, and the control group executes conventional gait rehabilitation treatment. The primary endpoint variable is the Functional Ambulation Category (FAC) that determines the degree of independent walking and is measured before, after, and after 4 weeks of treatment. Secondary endpoint variables are 11 variables that take into account motor function and range, measured at the same time as the primary endpoint variable. Discussion There are still insufficient data on the effectiveness of electromechanical-assisted gait training for stroke patients and large-scale research is lacking. Thus, the research described here is a large-scale study of stroke patients that can supplement the limitations mentioned in other previous studies. In addition, the clinical studies described here include physical epidemiological analysis parameters that can determine walking ability. The results of this study can lead to prove the generalizable effectiveness and safety of electromechanical-assisted gait training with EXOWALK®. Trial registration Clinical Research Information Service (CRIS), Republic of Korea KCT0003411, Registered on 30 October 2018

Rehabilitation robots have shown promise in improving the gait of children with childhood-onset motor disabilities. This study aimed to investigate the long-term benefits of training using a wearable Hybrid Assistive Limb (HAL) in these patients. Training using a HAL was performed for 20 min a day, two to four times a week, over four weeks (12 sessions in total). The Gross Motor Function Measure (GMFM) was the primary outcome measure, and the secondary outcome measures were gait speed, step length, cadence, 6-min walking distance (6MD), Pediatric Evaluation of Disability Inventory, and Canadian Occupational Performance Measure (COPM). Patients underwent assessments before the intervention, immediately after the intervention, and at 1-, 2-, 3-month and 1-year follow-ups. Nine participants (five males, four females; mean age: 18.9 years) with cerebral palsy (n = 7), critical illness polyneuropathy (n = 1), and encephalitis (n = 1) were enrolled. After training using HAL, GMFM, gait speed, cadence, 6MD, and COPM significantly improved (all p < 0.05). Improvements in GMFM were maintained one year after the intervention (p < 0.001) and in self-selected gait speed and 6MD three months after the intervention (p < 0.05). Training using HAL may be safe and feasible for childhood-onset motor disabilities and may maintain long-term improvements in motor function and walking ability. [ABSTRACT FROM AUTHOR]

Demand for wearable devices and supportive technology is growing as these devices have the potential to enhance physical function and quality of life in users. The purpose of this study was to investigate usability and satisfaction after performing functional and gait exercise with a wearable hip exoskeleton in community-living adults. A total of 225 adults residing in the local community participated in this study. All participants performed 40 min of exercise once with a wearable hip exoskeleton in various environments. The EX1, which functions as a wearable hip exoskeleton, was used. Physical function was assessed before and after exercise with the EX1. After completing exercise with the EX1, the usability and satisfaction questionnaires were evaluated. Gait speed, timed up and go test (TUG), and four square step test (FSST) showed statistically significant improvements after exercise with the EX1 in both groups (p < 0.05). In the 6 min walking test (6MWT), a significant increase was observed in the middle-aged group (p < 0.05). In the short physical performance battery (SPPB), there was a significant improvement in the old-aged group (p < 0.05). On the other hand, positive results in usability and satisfaction were noticed in both groups. These results demonstrate that a single session of exercise with the EX1 was effective in improving physical performance of both middle- and old-aged adults, with positive feedback from most of the participants. [ABSTRACT FROM AUTHOR]

Abstract Background This study was conducted to assess the effect of electromechanical-assisted gait training intensity on walking ability in patients over 3-month post-stroke. Methods Data from two randomized controlled trials (RCTs) were collected under the same study design of assessment and intervention, excluding intervention time per session. After matching the inclusion criteria of two RCTs, the experimental groups of each RCT were defined as low-intensive (LI) and high-intensive (HI) group according to the intervention time per session. Primary outcome was the difference of the change in Functional Ambulatory Categories (FAC) between LI and HI gait training. Secondary outcomes were the difference of changes in mobility, walking speed, walking capacity, leg-muscle strength, balance and daily activity evaluated with Rivermead Mobility Index (RMI), 10 m walk test (10MWT), 6-min walk test (6MWT), Motricity Index (MI), Berg Balance Scale (BBS) and Modified Barthel Index (MBI) respectively. Results The FAC improved after gait training in both groups. The secondary outcomes also improved in both groups except RMI and MI in HI group. The change of all outcomes were not different between groups except RMI. The change of RMI in the LI group was greater than that in the HI group statistically, but it did not meet minimal clinically important difference. Conclusions The improvement of walking ability after LI or HI gait training was not different if providing the same total gait training time. By providing the electromechanical gait training intensively, we could shorten the gait training period to improve walking ability and customize the training program according to the patient training abilities. Trial registration Name of the registry: Clinical Research Information Service. Trial registration number: No. KCT0002195(RCT1), No. KCT0002552(RCT2). Date of registration: 10/04/2016(RCT1), 10/05/2017(RCT2). URL of the trial registry record: https://cris.nih.go.kr/cris/search

BackgroundA large number of robotic or gravity-supporting devices have been developed for rehabilitation of upper extremity post-stroke. Because these devices continuously monitor performance data during training, they could potentially help to develop predictive models of the effects of motor training on recovery. However, during training with such devices, patients must become adept at using the new "tool" of the exoskeleton, including learning the new forces and visuomotor transformations associated with the device. We thus hypothesized that the changes in performance during extensive training with a passive, gravity-supporting, exoskeleton device (the Armeo Spring) will follow an initial fast phase, due to learning to use the device, and a slower phase that corresponds to reduction in overall arm impairment. Of interest was whether these fast and slow processes were related.MethodsTo test the two-process hypothesis, we used mixed-effect exponential models to identify putative fast and slow changes in smoothness of arm movements during 80 arm reaching tests performed during 20 days of exoskeleton training in 53 individuals with post-acute stroke.ResultsIn line with our hypothesis, we found that double exponential models better fit the changes in smoothness of arm movements than single exponential models. In contrast, single exponential models better fit the data for a group of young healthy control subjects. In addition, in the stroke group, we showed that smoothness correlated with a measure of impairment (the upper extremity Fugl Meyer score - UEFM) at the end, but not at the beginning, of training. Furthermore, the improvement in movement smoothness due to the slow component, but not to the fast component, strongly correlated with the improvement in the UEFM between the beginning and end of training. There was no correlation between the change of peaks due to the fast process and the changes due to the slow process. Finally, the improvement in smoothness due to the slow, but not the fast, component correlated with the number of days since stroke at the onset of training - i.e. participants who started exoskeleton training sooner after stroke improved their smoothness more.ConclusionsOur results therefore demonstrate that at least two processes are involved in in performance improvements measured during mechanized training post-stroke. The fast process is consistent with learning to use the exoskeleton, while the slow process independently reflects the reduction in upper extremity impairment.

Background: The classical description of poststroke upper limb impairment follows a proximalto-distal impairment gradient. Previous studies are equivocal on whether the hand is more impaired than the arm. Objective: To compare impairment of the arm and hand during subacute stroke. Method: A total of 73 individuals were evaluated for impairment of the upper limb within 30 days (early subacute) and within 90–150 days (late subacute) of stroke. Impairments were quantified using the Chedoke-McMaster Stroke Assessment (CMSA) for the arm and hand, Purdue Pegboard task, and a robotic Visually Guided Reaching task. Results: In the early phase 42% of participants in the early phase and 59% in the late phase received the same CMSA score for the arm and hand, with 88% and 95% of participants in the early and late phases, respectively, receiving a 1-point difference. Strong correlations exist between the CMSA arm and hand scores (early r = 0.79, late r = 0.75), and moderate – strong correlations exist between CMSA arm and hand scores and Purdue Pegboard and Visually Guided Reaching performances (r = 0.66–0.81). No systematic differences were found between the arm and hand. Conclusion: Impairments in the arm and hand during subacute stroke are highly correlated and do not support the presence of a proximal-to-distal gradient. LAY ABSTRACT Motor impairments are a common occurrence after stroke, and are classically believed to present in a gradient from more impairment in the hand to less impairment in the arm. In this study, participants who had recently had a stroke underwent assessment with the Chedoke-McMaster Stroke Assessment, the Purdue Pegboard task, and a Visually Guided Reaching task to quantify impairment and performance of the arm and hand. Levels of impairment in the arm and hand, as measured with the Chedoke-McMaster Stroke Assessment, were found to be highly correlated. The study also showed strong correlations between quantitative measures of performance for both the arm and hand. Overall, our results do not support the presence of a proximal-to-distal gradient of impairment during subacute stroke.

Background: Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort. Methods: A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and therapy costs. We estimate cost-effectiveness using the incremental cost utility ratio and present results on the cost-effectiveness plane and on cost-effectiveness acceptability curves. Results: Participants in the prospective, practice-based cohort with complete EQ-5D data (n = 99) qualified for the analysis. Both conventional training and overground robotic training experienced an improvement in QALYs. Only people with incomplete SCI improved with conventional locomotor training, 0.045 (SD 0.28), and only people with complete SCI improved with overground robotic training, 0.097 (SD 0.20). Costs were lower for conventional training, $1758 (SD $1697) versus overground robotic training $3952 (SD $3989), and lower for those with incomplete versus complete injury. Conventional overground training was more effective and cost less than robotic therapy for people with incomplete SCI. Overground robotic training was more effective and cost more than conventional training for people with complete SCI. The incremental cost utility ratio for overground robotic training for people with complete spinal cord injury was $12,353/QALY. Conclusions: The most cost-effective locomotor training strategy for people with SCI differed based on injury completeness. Conventional training was more cost-effective than overground robotic training for people with incomplete SCI. Overground robotic training was more cost-effective than conventional training for people with complete SCI. The effect estimates may be subject to limitations associated with small sample sizes and practice-based evidence methodology. These estimates provide a baseline for future research. [ABSTRACT FROM AUTHOR]

We compared changes in spatiotemporal gait parameters of 11 healthy older adults (mean age: 88.6 years) over 3 conditions of walking with the Honda Walking Assist (HWA), a hip-assistive exoskeleton. Differences in 14 gait parameters between (1) normal overground walking, (2) walking with a nonassisting HWA, and (3) optimally assisting HWA were analyzed using Friedman and Wilcoxon signed rank tests. Significant differences depending on type of assistance were found for 9 parameters. None persisted following Bonferroni corrections. Single-session individualized HWA assistance does not induce immediate changes in gait parameters. This does not contradict the potential of multiple training sessions with the HWA. [ABSTRACT FROM AUTHOR]

Robot-assisted gait training (RAGT) provides a task-based support of walking using exoskeletons. Evidence shows moderate, but positive effects in the therapy of patients with cerebral palsy (CP). This study investigates the impact of RAGT on walking speed and gait parameters in pediatric CP patients. Thirty subjects (male = 23; female = 7), with a mean age of 13.0 ± 2.5 (9–17) years, and with spastic CP, were recruited. The intervention group (n = 15) underwent six 20-minute RAGT sessions with the Hybrid Assistive Limb (HAL) during an 11-day hospital stay. Additionally, a therapy concept including physiotherapy, physician-performed manual medicine, massage and exercise therapy was provided. The control group (n = 15) was treated with the therapy concept only. The outcome was based on a 10-Metre Walking Test (10MWT), 6-Minute Walking Test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion. The intervention group achieved a mean increase in walking speed in the 10MWT (self-selected walking speed SSW) of 5.5 s (p = 0.378). There were no significant differences between the groups in the 10MWT (max) (p = 0.123) and the 6MWT (p = 0.8). Changes in the GMFM (total) and in the dimension standing and walking, running and jumping (D + E) showed clinically relevant significant results (p = 0.002 and p = 0.046). RAGT as a supplement to an inpatient therapy stay appears to have a positive, yet not significant impact on the gait parameters of pediatric CP patients as well as motivating them to practice walking. Further studies with adapted study designs are needed to evaluate different influencing factors. [ABSTRACT FROM AUTHOR]

To explore the experience and acceptability of an exoskeleton-based physiotherapy program for non-ambulatory patients during subacute stroke rehabilitation from the perspective of patients and therapists. This was a qualitative descriptive study using semi-structured interviews and thematic analysis. Fourteen patients with stroke who participated in the experimental arm of a randomized controlled trial investigating the efficacy of exoskeleton-based physiotherapy were recruited. Six physiotherapists who provided the intervention were also recruited. Three themes were identified relating to the experience and acceptability of an exoskeleton-based physiotherapy program: (1) A matter of getting into the swing of things depicted the initial and ongoing learning process of using an exoskeleton; (2) More of a positive experience than anything else described the participants' mostly favorable attitude toward exoskeleton-based gait training; and (3) The best step forward captured participant-identified recommendations and considerations for the future integration of exoskeleton training into stroke rehabilitation. Patients with stroke were even more optimistic than therapists toward the experience and benefits of exoskeleton-based gait training during subacute stroke rehabilitation. Future clinical practice should consider the balance between actual and perceived benefits, as well as the potential barriers to integrating an exoskeleton into stroke rehabilitation. Powered robotic exoskeletons can be used to provide higher duration and more repetitious walking practice for non-ambulatory patients with stroke. Patients with stroke view exoskeleton-based physiotherapy highly favorably, attributing greater opportunity and benefit to using the device during subacute rehabilitation. Physiotherapists should consider learning challenges, patient characteristics, and implementation barriers when integrating exoskeleton-based training within a treatment program. [ABSTRACT FROM AUTHOR]

In this study, we aimed to evaluate the short-term outcomes of a rehabilitation program with the Hybrid Assistive Limb® after soft tissue lengthening in young patients with cerebral palsy. We assessed six patients with cerebral palsy who underwent soft tissue surgery followed by gait training using the Hybrid Assistive Limb®. Clinical assessments were conducted preoperatively, before, immediately after, and at 1, 2, and 3 months after gait training. Gross Motor Function Measure was improved 5.93 ± 6.11% (mean ± standard deviation, p < 0.05), Canadian Occupational Performance Measure performance was improved 3.12 ± 1.53 points, and satisfaction was improved 3.80 ± 2.14 points (p < 0.05). The knee extension strength on the operated side was changed 7.75 ± 4.97 Nm after the intervention (p = 0.07). In ambulatory patients, gait speed was changed 8.37 ± 1.72 m/min, stride length was changed 10 ± 6.16 cm, and 6 min walking distance was changed 52 ± 16 m after the intervention. Training with the Hybrid Assistive Limb® may improve walking ability and clinical outcomes in young patients with cerebral palsy after soft tissue lengthening. [ABSTRACT FROM AUTHOR]

Hand-function recovery is often a goal for stroke survivors undergoing therapy. This work aimed to design, build, and verify a pneumatic hand training device for its eventual use in post-stroke rehabilitation. The system was built considering prior research in the field of robotic hand rehabilitation as well as specifications and design constraints developed with physiotherapists. The system contained pneumatic airbag actuators for the fingers and thumb of the hand, a set of flex, pressure, and flow sensors, and software and hardware controls. An experiment with the system was carried out on 30 healthy individuals. The sensor readings were analyzed for repeatability and reliability. Position sensors and an approximate biomechanical model of the index finger were used to estimate joint angles during operation. A survey was also issued to the users to evaluate their comfort levels with the device. It was found that the system was safe and comfortable when moving the fingers of the hand into an extension.

In recent decades, extensive attention has been paid to the study and development of robotic devices specifically designed for hand rehabilitation. Accordingly, a many concepts concerning rigid, soft, and hybrid types have emerged in the literature, with significant ongoing activity being directed towards the development of new solutions. In this context, the paper focuses on the technical features of devices conceived for the robotic rehabilitation of the hand with reference to the three kinds of exoskeleton architecture and the clinical requirements demanded by the target impairment of the end-user. The work proposes a roadmap (i) for both the design and selection of exoskeletons for hand rehabilitation, (ii) to discriminate among the peculiarities of soft, rigid, and hybrid devices, and (iii) with an impairment-oriented rationale. The clinical requirements expected for an exoskeleton are identified by applying a PICO-inspired approach focused on the impairment analysis; the technical features are extracted from a proposed design process for exoskeletons combined with a narrative literature review. A cross-analysis between device families and features is presented to provide a supporting tool for both the design and selection of exoskeletons according to an impairment-oriented rationale.

Abstract Background Many older Americans suffer from long-term upper limb dysfunction, decreased grip strength, and/or a reduced ability to hold objects due to injuries and a variety of age-related illnesses. The objective of this study was to design and build a five-fingered powered assistive exoskeleton for the human hand, and to validate its ability to augment the gripping and pinching efforts of the wearer and assist in performing ADLs. Methods The exoskeleton device was designed using CAD software and 3-D printed in ABS. Each finger’s movement efforts were individually monitored by a force sensing resistor at each fingertip, and proportionally augmented via the microcontroller-based control scheme, linear actuators, and rigid exoskeleton structure. The force production of the device and the force augmenting capability were assessed on ten healthy individuals with one 5-digit grasping test, three pinching tests, and two functional tests. Results Use of the device significantly decreased the forearm muscle activity necessary to maintain a grasping effort (67%, p

ObjectiveThe prevention and treatment of secondary complications is a key priority for people with spinal cord injury and a fundamental goal of rehabilitation. Activity-based Training (ABT) and Robotic Locomotor Training (RLT) demonstrate promising results for reducing secondary complications associated with SCI. However, there is a need for increased evidence through randomized controlled trials. Therefore, we aimed to investigate the effect of RLT and ABT interventions on pain, spasticity, and quality of life in individuals with spinal cord injuries.MethodsParticipants with chronic motor incomplete tetraplegia (n = 16) were recruited. Each intervention involved 60-minute sessions, 3× per week, over 24-weeks. RLT involved walking in an Ekso GT exoskeleton. ABT involved a combination of resistance, cardiovascular and weight-bearing exercise. Outcomes of interest included the Modified Ashworth Scale, the International SCI Pain Basic Data Set Version 2, and the International SCI Quality of Life Basic Data Set.ResultsNeither intervention altered symptoms of spasticity. Pain intensity increased from pre-post intervention for both groups, with a mean increase of 1.55 [−0.82, 3.92] (p = 0.03) and 1.56 [−0.43, 3.55] (p = 0.02) points for the RLT and ABT group, respectively. The ABT group had an increase in pain interference scores of 100%, 50%, and 109% for the daily activity, mood, and sleep domain, respectively. The RLT group had an increase in pain interference scores of 86% and 69% for the daily activity and mood domain respectively, but no change in the sleep domain. The RLT group had increased perceptions of quality of life with changes of 2.37 [0.32, 4.41], 2.00 [0.43, 3.56] and 0.25 [−1.63, 2.13] points, p = 0.03, for the general, physical, and psychological domains, respectively. The ABT group had increased perceptions of general, physical and psychological quality of life with changes of 0.75 [−1.38, 2.88], 0.62 [−1.83, 3.07] and 0.63 [−1.87, 3.13] points, respectively.ConclusionsDespite increased pain ratings and no change in symptoms of spasticity, there was an increase in perceived quality of life for both groups over 24-weeks. This dichotomy warrants additional investigation in future large-scale randomized controlled trials.

ObjectiveBrain-computer interface (BCI) technology is attracting increasing interest as a tool for enhancing recovery of motor function after stroke, yet the optimal way to apply this technology is unknown. Here, we studied the immediate and therapeutic effects of BCI-based training to control pre-movement sensorimotor rhythm (SMR) amplitude on robot-assisted finger extension in people with stroke.ApproachEight people with moderate to severe hand impairment due to chronic stroke completed a four-week three-phase protocol during which they practiced finger extension with assistance from the FINGER robotic exoskeleton. In Phase 1, we identified spatiospectral SMR features for each person that correlated with the intent to extend the index and/or middle finger(s). In Phase 2, the participants learned to increase or decrease SMR features given visual feedback, without movement. In Phase 3, the participants were cued to increase or decrease their SMR features, and when successful, were then cued to immediately attempt to extend the finger(s) with robot assistance.Main resultsOf the four participants that achieved SMR control in Phase 2, three initiated finger extensions with a reduced reaction time after decreasing (versus increasing) pre-movement SMR amplitude during Phase 3. Two also extended at least one of their fingers more forcefully after decreasing pre-movement SMR amplitude. Hand function, measured by the box and block test (BBT), improved by 7.3  ±  7.5 blocks versus 3.5  ±  3.1 blocks in those with and without SMR control, respectively. Higher BBT scores at baseline correlated with a larger change in BBT score.SignificanceThese results suggest that learning to control person-specific pre-movement SMR features associated with finger extension can improve finger extension ability after stroke for some individuals. These results merit further investigation in a rehabilitation context.

The goal of this study was to determine the relative contributions of finger weakness and reduced finger individuation to reduced hand function after stroke, and their association with corticospinal tract (CST) injury.We measured individuated and synergistic maximum voluntary contractions (MVCs) of the index and middle fingers, in both flexion and extension, of 26 individuals with a chronic stroke using a robotic exoskeleton. We quantified finger strength and individuation, and defined a novel metric that combines them - "multifinger capacity". We used stepwise linear regression to identify which measure best predicted hand function (Box and Blocks Test, Nine Hole Peg Test) and arm impairment (the Upper Extremity Fugl-Meyer Test).Compared to metrics of strength or individuation, capacity survived the stepwise regression as the strongest predictor of hand function and arm impairment. Capacity was also most strongly related to presence or absence of lesion overlap with the CST.Reduced strength and individuation combine to shrink the space of achievable finger torques, and it is the resulting size of this space - the multifinger capacity - that is of elevated importance for predicting loss of hand function.Multi-finger capacity may be an important target for rehabilitative hand training.

Exoskeletons are externally worn motorized devices that assist with sit-to-stand and walking in individuals with motor and functional impairments. The Food & Drug Administration (FDA) has approved several of these technologies for clinical use however, there is limited evidence to guide optimal utilization in every day clinical practice. With the diversity of technologies & equipment available, it presents a challenge for clinicians to decide which device to use, when to initiate, how to implement these technologies with different patient presentations, and when to wean off the devices. Thus, we present a clinical utilization framework specific to exoskeletons with four aims.These aims are to assist with clinical decision making of when exoskeleton use is clinically indicated, identification of which device is most appropriate based on patient deficits and device characteristics, providing guidance on dosage parameters within a plan of care and guidance for reflection following utilization. This framework streamlines how clinicians can approach implementation through the synthesis of published evidence with appropriate clinical assessment & device selection to reflection for success and understanding of these innovative & complex technologies. [ABSTRACT FROM AUTHOR]

Background: High-intensity repetitive task-specific practice might be the most effective strategy to promote motor recovery after stroke, and electromechanical-assisted gait training represents one of the treatment options. However, there is still difficulty in clarifying the difference between conventional gait training and electromechanically assisted gait training.Methods: The study is a multicenter, randomized, parallel-group clinical trial for stroke patients. Three clinical research centers in Korea (Dongguk University Ilsan Hospital, Chungnam National University Hospital, and Seoul National University Bundang Hospital) will participate in the clinical trial and 144 stroke patients will be registered. Enrolled patients are assigned to two groups, an experimental group and a control group, according to a randomization table. In addition, patients are treated for half an hour (one session) five times a week for 4 weeks. Both groups carry out basic rehabilitation (central nervous system development therapy and strength exercise) and the experimental group executes robotic walking rehabilitation treatment, and the control group executes conventional gait rehabilitation treatment. The primary endpoint variable is the Functional Ambulation Category (FAC) that determines the degree of independent walking and is measured before, after, and after 4 weeks of treatment. Secondary endpoint variables are 11 variables that take into account motor function and range, measured at the same time as the primary endpoint variable.Discussion: There are still insufficient data on the effectiveness of electromechanical-assisted gait training for stroke patients and large-scale research is lacking. Thus, the research described here is a large-scale study of stroke patients that can supplement the limitations mentioned in other previous studies. In addition, the clinical studies described here include physical epidemiological analysis parameters that can determine walking ability. The results of this study can lead to prove the generalizable effectiveness and safety of electromechanical-assisted gait training with EXOWALK®.Trial Registration: Clinical Research Information Service (CRIS), Republic of Korea KCT0003411, Registered on 30 October 2018. [ABSTRACT FROM AUTHOR]

Humans naturally employ muscle coactivation to facilitate a broad range of movements, enhancing joint stability and movement accuracy. However, excessive muscle coactivation can become unfavorable or even detrimental. This phenomenon is often observed in industrial workers who endure repetitive or prolonged joint stress, particularly in areas such as the shoulders. Prolonged stress can result in soft tissue damage and the onset of work-related musculoskeletal disorders (MSDs). In recent years, there have been efforts to mitigate the emergence of work-related MSDs among industrial workers through the implementation of upper-limb occupational exoskeletons (OEs). While previous research has demonstrated their effectiveness in reducing shoulder muscle activation, particularly in static and overhead work activities, there has been a lack of studies examining the impact of upper-limb OEs on muscle coactivation during repetitive arm movements. To bridge this gap in knowledge, our study systematically assesses the influence of a passive exoskeleton's anti-gravitational support on shoulder muscle coactivation during repetitive arm movements. Results show that peak and mean coactivation levels linearly decrease with the increase of the amount of anti-gravitational support provided by the upper-limb OE, reaching approximately 51% and 54%, respectively. Conversely, the percentage of the movement cycle corresponding to the coactivation peak appears unaffected by the level of assistance. This study marks the first instance in which a passive upper-limb OE has been shown to reduce shoulder muscle coactivations, potentially paving the way for a novel methodology in their evaluation., Competing Interests: Declarations Competing interests F. G., N. V., and S. C. have commercial interests in IUVO S. r. l. (Pontedera, Italy), a spinoff company of Scuola Superiore Sant’Anna. IUVO S. r. l. has developed the MATE-XT technology and owns the IP protecting the technology, which is licensed to COMAU S.p. A. (Grugliasco, Italy) for commercial purposes in the industrial market. F. G. is the head of the R&D unit of IUVO S.r.l.. N.V. and S.C. are scientific advisors of IUVO S.r.l.. The other authors declare no competing interests., (© 2024. The Author(s).)

This review discusses non-pharmacological, non-surgical interventions for action tremor, including essential tremor (ET). We review transcutaneous peripheral nerve stimulation (PNS), a variety of orthotic/mechanical devices, cooling and vibration strategies, and adaptive utensils, most of which are currently available. The PNS section discusses open loop (CALA-Trio) and closed loop systems (Felix™, NeuroAI™ and Motimove® systems). Orthotic devices which physically dampen tremor include Tremulo™, GyroGlove™, WOTAS exoskeleton, Magnetorheological Fluid-Based Exoskeleton System, Steadi-One® and Steadi-Two®, and Readi-Steady®. Adaptive devices include weighted spoons, deep cavity spoons, counter-balance utensils, and electrical actuator devices. Despite availability, most of these devices have limited to no published clinical trial data., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Recent advancements in exoskeleton technology, both passive and active, are driven by the need to enhance human capabilities across various industries as well as the need to provide increased safety for the human worker. This review paper examines the sensors, actuators, mechanisms, design, and applications of passive and active exoskeletons, providing an in-depth analysis of various exoskeleton technologies. The main scope of this paper is to examine the recent developments in the exoskeleton developments and their applications in different fields and identify research opportunities in this field. The paper examines the exoskeletons used in various industries as well as research-level prototypes of both active and passive types. Further, it examines the commonly used sensors and actuators with their advantages and disadvantages applicable to different types of exoskeletons. Communication protocols used in different exoskeletons are also discussed with the challenges faced.

Guidelines encouraging social distancing, limited outings, and remote work due to COVID-19 have increased sedentary periods and reduced levels of physical activity. These habits increase the risk of metabolic diseases, obesity, cardiovascular disease, and diabetes mellitus. The World Health Organization recommends muscle-strengthening exercises as well as regular physical activity to promote overall health. This study investigates the effect of a wearable hip exoskeleton on muscle activity and heart rate during anaerobic exercise in 40 healthy adults (mean age of 40.00 ± 11.51 years; n = 20 females). Bot Fit, a wearable hip-type robotic exoskeleton, was developed by Samsung Electronics Co., Ltd. (Suwon, Republic of Korea) to enhance the effects of both aerobic and anaerobic exercise. All study participants performed a fitness exercise protocol, including knee-ups, good mornings, squats, mountain climbs, kick-backs, reverse lunges, and split jacks, with and without a Bot Fit. To evaluate the effect of anaerobic exercise with the Bot Fit, muscle activity and heart rate were measured during fitness exercises with and without a Bot Fit. Measured muscles were the rectus abdominis (RA), erector spinae (ES), rectus femoris (RF), vastus lateralis (VL), vastus medialis (VM), biceps femoris (BF), tibialis anterior (TA), gastrocnemius medialis (GCM), and gluteus maximus (GM). During anaerobic exercises with the Bot Fit, there was a significant increase in muscle activity compared to exercising without the Bot Fit. Muscle activity increased significantly in the RA, RF, VL, BF and TA muscles during knee-ups; in the ES, BF, and GM during good mornings; in the RF, VL, VM, BF, and GM during squats; in RA, RF, VL, VM, and GM during mountain climbs; in the RA and BF during kick-backs; in the RF, BF, and GCM during reverse lunges; and in the RF and VL during split jacks (p < 0.05). Heart rates showed a statistically significant increase during good mornings, mountain climbs, and reverse lunge exercises while wearing the Bot Fit (p < 0.05). This study demonstrated that anaerobic exercises by healthy adults using a Bot Fit led to enhanced activation of abdominal and lower-limb muscles as well as an improved heart rate, maximizing the effect of anaerobic exercise compared with the same exercise protocol without a Bot Fit. This suggests that use of a Bot Fit can increase the effectiveness of anaerobic exercise in healthy adults., (© 2024. The Author(s).)

Nowadays, exoskeletons have a place in many fields, such as industrial production, medical rehabilitation, and military. However, there are still many shortcomings in the existing exoskeleton, such as heavyweight and complex structures for active exoskeleton. The driving ability of passive exoskeletons is limited. To reduce the energy consumption of wearers, based on the characteristics of the semi-active ankle exoskeleton, this paper proposes to use NiTiCu-based shape memory alloys (SMA) as the energy storage source to improve the power density. Compared to NiTi-based SMA, the phase transformation process of NiTiCu-based SMA is more rapid, which can solve the response delay problem to a certain extent. The ankle exoskeleton uses SMA deformation to compress the bias spring. When the human ankle joint needs auxiliary torque, the SMA releases the energy stored by the bias spring and transfers the energy to the ankle exoskeleton to achieve the effect of assisting the human ankle joint. During the assistance process, a control system based on the SMA mathematical model is constructed. The above-mentioned ideas provide a new approach for further expanding power density and can be widely applied in the field of robotics. During characterization, this semi-active ankle exoskeleton can effectively complete the movement state of upstairs and walking, achieve an effective power of 180 N, and store maximum energy up to 5 J for the human ankle., (© 2024 Author(s). Published under an exclusive license by AIP Publishing.)

Lower-limb exoskeletons have the potential to transform the way we move 1-14 , but current state-of-the-art controllers cannot accommodate the rich set of possible human behaviours that range from cyclic and predictable to transitory and unstructured. We introduce a task-agnostic controller that assists the user on the basis of instantaneous estimates of lower-limb biological joint moments from a deep neural network. By estimating both hip and knee moments in-the-loop, our approach provided multi-joint, coordinated assistance through our autonomous, clothing-integrated exoskeleton. When deployed during 28 activities, spanning cyclic locomotion to unstructured tasks (for example, passive meandering and high-speed lateral cutting), the network accurately estimated hip and knee moments with an average R 2 of 0.83 relative to ground truth. Further, our approach significantly outperformed a best-case task classifier-based method constructed from splines and impedance parameters. When tested on ten activities (including level walking, running, lifting a 25 lb (roughly 11 kg) weight and lunging), our controller significantly reduced user energetics (metabolic cost or lower-limb biological joint work depending on the task) relative to the zero torque condition, ranging from 5.3 to 19.7%, without any manual controller modifications among activities. Thus, this task-agnostic controller can enable exoskeletons to aid users across a broad spectrum of human activities, a necessity for real-world viability., Competing Interests: Competing interests D.D.M. and A.J.Y. are inventors on a patent filed with the US Patent Office (US 18/340,981) by the Georgia Institute of Technology that covers some of the methods for state estimation described in this work. X, The Moonshot Factory, funded this work, contributed to its conceptualization and methodological design, and contributed much of the exoskeleton hardware and software used in this study., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Virtual Reality (VR) has proven to be an effective tool for motor (re)learning. Furthermore, with the current commercialization of low-cost head-mounted displays (HMDs), immersive virtual reality (IVR) has become a viable rehabilitation tool. Nonetheless, it is still an open question how immersive virtual environments should be designed to enhance motor learning, especially to support the learning of complex motor tasks. An example of such a complex task is triggering steps while wearing lower-limb exoskeletons as it requires the learning of several sub-tasks, e.g., shifting the weight from one leg to the other, keeping the trunk upright, and initiating steps. This study aims to find the necessary elements in VR to promote motor learning of complex virtual gait tasks., Methods: In this study, we developed an HMD-IVR-based system for training to control wearable lower-limb exoskeletons for people with sensorimotor disorders. The system simulates a virtual walking task of an avatar resembling the sub-tasks needed to trigger steps with an exoskeleton. We ran an experiment with forty healthy participants to investigate the effects of first- (1PP) vs. third-person perspective (3PP) and the provision (or not) of concurrent visual feedback of participants' movements on the walking performance - namely number of steps, trunk inclination, and stride length -, as well as the effects on embodiment, usability, cybersickness, and perceived workload., Results: We found that all participants learned to execute the virtual walking task. However, no clear interaction of perspective and visual feedback improved the learning of all sub-tasks concurrently. Instead, the key seems to lie in selecting the appropriate perspective and visual feedback for each sub-task. Notably, participants embodied the avatar across all training modalities with low cybersickness levels. Still, participants' cognitive load remained high, leading to marginally acceptable usability scores., Conclusions: Our findings suggest that to maximize learning, users should train sub-tasks sequentially using the most suitable combination of person's perspective and visual feedback for each sub-task. This research offers valuable insights for future developments in IVR to support individuals with sensorimotor disorders in improving the learning of walking with wearable exoskeletons., (© 2024. The Author(s).)

Shoulder exosuits are a promising new technology that could enable individuals with neuromuscular impairments to independently perform activities of daily living, however, scarce evidence exists to evaluate their ability to support such activities. Consequently, it is not understood how humans adapt motion in response to assistance from a shoulder exosuit. In this study, we developed a cable-driven shoulder exosuit and evaluated its effect on reaching and drinking tasks within a cohort of 18 healthy subjects to quantify changes to muscle activity and kinematics as well as trial-to-trial learning in duration and actuator switch timing. The exosuit successfully reduced mean muscle activity in the middle (reaching: 23.4 ± 26.3%, drinking: 20.0 ± 25.1%) and posterior (reaching: 12.8 ± 10.3%, drinking: 4.0 ± 7.2%) deltoid across both functional tasks. Likewise, the exosuit reduced integrated muscle activity in the middle deltoid (reaching: 22.2 ± 22.7%, drinking: 14.9 ± 27.0%). Exosuit assistance also altered kinematics such that individuals allowed their arms to follow forces applied by the exosuit. In terms of learning, subjects reduced movement duration by 15.6 ± 11.9% as they practiced using the exosuit. Reducing movement duration allowed subjects to reduce integrated muscle activity in the anterior (15.2 ± 10.3%), middle (14.7 ± 9.7%), and posterior (14.8 ± 9.7%) deltoids. Similarly, subjects activated the actuator switch earlier over the course of many assisted trials. The muscle activity reductions during both reaching and drinking demonstrate the promise of shoulder exosuits to enable independent function among individuals with neuromuscular impairments. The kinematic response to assistance and learning features observed in movement duration provide insight into human-exosuit interaction principles that could inform future exosuit development. NEW & NOTEWORTHY Shoulder exosuits assist arm function, but it is not understood how assistance affects motion. We evaluated spatiotemporal movement features and muscle activity during assisted and unassisted arm motions. Introducing the exosuit caused individuals to let their arms follow assistive forces. Furthermore, individuals learned to use the exosuit with practice by moving more quickly to reduce cumulative effort and by activating assistance earlier. These results demonstrate that individuals adapt exosuit-assisted motion to reduce effort.

While back-support exoskeletons are increasing in popularity as an ergonomic intervention for manual material handling, they may cause alterations to neuromuscular control required for maintaining spinal stability. This study evaluated the effects of soft and rigid passive exoskeletons on trunk local dynamic stability and trunk-pelvis coordination. Thiry-two young (18-30 years) and old (45-60 years) men and women completed repetitive lifting and lowering tasks using two different exoskeletons and in a control condition. Both exoskeletons significantly reduced the short-term maximum Lyapunov exponent (LyE) of the trunk (p < 0.01), suggesting improved local dynamic stability. There was also a significant main effect of age (p = 0.05): older adults exhibited lower short-term LyE that young adults. Use of the soft exoskeleton significantly increased, while the rigid exoskeleton significantly decreased, long-term LyE, and these changes were more pronounced in the young group compared to the old group. Additionally, exoskeleton use resulted in significant increase (p < 0.001) of mean absolute relative phase (MARP) and deviation phase (DP) by ∼30-60 %, with greater increases due to the rigid than the soft device. Thus, trunk-pelvic coordination and coordination variability were negatively impacted by exoskeleton use. Potential reasons for these findings may include exoskeleton-induced changes in lifting strategy, reduced peak trunk flexion velocity, and cycle-to-cycle variability of trunk velocity. Furthermore, although the soft and rigid devices caused comparable changes in trunk-extensor muscle activity, they exhibited differential effects on long-term maximum Lyapunov exponents as well as trunk-pelvic coordination, indicating that exoskeleton design features can have complex effects on trunk neuromuscular control., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Exosuits have the potential to mitigate musculoskeletal stress and prevent back injuries during industrial tasks. This study aimed to 1) validate the implementation of a soft active exosuit into a musculoskeletal model of the spine by comparing model predicted muscle activations versus corresponding surface EMG measurements, and 2) evaluate the effect of the exosuit on peak back and hip muscle forces. Fourteen healthy participants performed squat and stoop lift and lower tasks with boxes of 6 and 10 kg, with and without wearing a 2.7 kg soft active exosuit. Participant-specific musculoskeletal models, which included the exosuit, were created in OpenSim. Model validation focused on the back and hip extensors, where temporal agreement between EMG and model estimated muscle activity was generally strong to excellent (average cross-correlation coefficients ranging from 0.84 to 0.98). Root mean square errors of muscle activity (0.05-0.10) were similar with and without the exosuit, and compared well to prior model validation studies without the exosuit (average root mean square errors ranging from 0.05 to 0.19). In terms of performance, the exosuit reduced the estimated peak erector spinae forces during lifting and lowering phases across all lifting tasks but reduced peak hip extensor muscles forces only in a squat lift task of 10 kg. These reductions in total peak muscle forces were approximately 1.7-4.2 times greater than the corresponding exosuit assistance force, which were 146 ± 19 N and 102 ± 14 N at the times of peak erector spinae forces in lifting and lowering, respectively. Overall, the results support the hypothesis that exosuits reduce soft tissue loading, and thereby potentially reduce fatigue and injury risk during manual materials handling tasks. Incorporating exosuits into musculoskeletal models is a valid approach to understand the impact of exosuit assistance on muscle activity and forces., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the effectiveness of passive back-support exosuit on postural control and cognitive performance during a fatigue-inducing posture maintenance task., Background: Wearable support systems (exoskeletons/exosuits) reduce physical demands but may also influence postural control and cognitive performance by reducing muscular fatigue., Method: Eighteen participants visited on two different days to test an exosuit system and performed dual-task cognitive assessments based on human information processing (information acquisition, information integration, and action implementation) while maintaining a 35° trunk flexion posture for 16 minutes. Center-of-pressure (CoP), cognitive performance, and perceived workload were recorded, while erector spinae muscle activity was captured to quantify muscle fatigue., Results: The exosuit was effective in reducing erector spinae muscle fatigue during the static posture maintenance task (61% less in Δmedian frequency: -9.5 Hz (EXO-Off) versus -3.7 Hz (EXO-On)). The fatigue-inducing task increased CoP velocity as a function of time (29% greater: 9.3 mm/sec (pre) versus 12.0 mm/sec (post)), and exosuit use decreased CoP velocity (23% less: 12.1 mm/sec (EXO-Off) versus 9.4 mm/sec (EXO-On)). The exosuit was also effective at mitigating cognitive degradation, as evidenced by a higher hit-to-signal ratio (8% greater: 81.3 (EXO-Off) versus 87.9 (EXO-On)) in the information integration task and reducing perceived workload in all stages of human information processing., Conclusion: Exosuit provided benefits of postural control and information integration processing during a 16-min static posture maintenance task., Application: Torso exoskeletons/suits can have positive implications for occupations with concurrent physical and cognitive demands.

Purpose: We investigated the influence of passive arm-support exoskeleton (ASE) with different levels of torque (50, 75, and 100%) on upper arm osteokinematics., Methods: Twenty participants completed a cyclic overhead drilling task with and without ASE. Task duration, joint angles, and angular acceleration peaks were analyzed during ascent and descent phases of the dominant upper arm., Results: Maximum ASE torque was associated with decreased peak acceleration during ascent (32.2%; SD 17.8; p < 0.001) and descent phases (38.8%; SD 17.8; p < 0.001). Task duration remained consistent. Increased torque led to a more flexed (7.2°; SD 5.5; p > 0.001) and internally rotated arm posture (17.6°; SD 12.1; p < 0.001), with minimal changes in arm abduction., Conclusion: The small arm accelerations and changes in osteokinematics we observed, support the use of this ASE, even while performing overhead cyclic tasks with the highest level of support., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)