Robotic devices can expand the repertoire of rehabilitation methods by enabling actions that cannot be replicated by a physical therapist. We previously developed a technique, we term ‘rapid assistance,’ that can assist movements beginning within the electromechanical delay between muscle activation and muscle contraction. Here, we evaluated the effects of repeated arm extension training with rapid assistance in older adults (n = 18) during a single session. We compared training with rapid assistance to a control group that performed unassisted arm extension training. Participants positively adapted to rapid assistance indicated by quickening reaction times (15.69%, t = -1.79, p = 0.089, d = 0.36) and greater extension angular velocities (47.93%, t = 3.47, p = 0.002, d = 0.56) compared to the control group following training. These motor performance improvements following rapid assistance training may be due to reducing Golgi-tendon inhibition during muscle contraction thereby, introducing an alternate strategy to improve motor performance. This specialized assistive timing may address a trade-off present in rehabilitative practice between assisting a patient or sufficiently challenging them to facilitate functional recovery.

Although humans employ various strategies to minimize metabolic cost, walking still has a substantial cost. Half of this cost comes from leg work to accelerate and decelerate the center of mass (CoM) in the anteroposterior direction. Studies showed how applying forward forces to assist CoM acceleration drastically reduces metabolic cost. However, the effect of combining this with assisting deceleration remains unclear. Here we show that oscillating forward and backward forces with zero net work in total can also reduce the metabolic cost by 11%. In the first part of this manuscript, we used a robotic tether to apply timed forces and found forward forces are most effective when applied around the middle of the double stance (approximately 0-30% of the step cycle), whereas the optimal window for backward forces was broader, spanning roughly 50-80% of the step cycle, and the effect of timing was not strong for this force direction. Nevertheless, the results suggest that a passive device, such as a mass-spring system, could also reduce metabolic cost. In the second part, we describe simulations and experiments of walking with a wheeled mass-spring system. Simulations suggest that certain stiffnesses could reduce the estimated metabolic cost. However, human experiments showed around 60% increase in metabolic cost rather than a reduction, likely due to friction and suboptimal timings. The finding that the results did not match theoretical predictions is similar to challenges in other wearable robotics studies.

Biofeedback is effective in modifying and improving targeted gait parameters in both healthy individuals and those with chronic stroke. However, prior studies have largely focused on the variable targeted by biofeedback and rarely report changes in other gait features. Given the interdependent nature of gait, alterations in one parameter may induce changes in other features. Thus, we aimed to determine whether tactile biofeedback to the plantar surfaces instructing stance time increases would increase propulsive gait features, such as trailing limb angles (TLA), peak propulsive forces, and propulsive impulses. 8 healthy individuals walked with tactile stimulation instructing varying levels of stance time increase targets (small, medium, and large) to one limb at a time. These stance time targets were calculated using symmetry ratios ranging from 0.775-1.225. This feedback instructed subjects to delay their push off, and thus their toe off, after a heel strike. During the large stance time increase feedback target, subjects increased their stance time (0.23 ± 0.02 seconds, p < 0.001), and consequently their TLA (8.1 ± 0.8°, p = 0.001), peak propulsion (8.1 ± 1.1%BW, p = 0.002), and their propulsive impulse (2.9 ± 0.3%BW·s, p = 0.002) compared to no feedback. Stance time changes were significantly correlated to TLA (R2 = 0.80, p < 0.001), and propulsive impulse (R2 = 0.81, p < 0.001), but to a lesser degree for peak propulsive force (R2 = 0.72, p < 0.001) when accounting for subject variances. These results provide evidence for a biofeedback tool that influences propulsive features that only instructs stance times. This may demonstrate the future application of a cheaper alternative for stroke survivors to improve the propulsion of the paretic limb compared to external assistances such as exoskeletons or ground reaction force biofeedback. Such a device could be an effective tool in post-stroke gait rehabilitation, for targeting improvements in the temporal and propulsive function of the paretic limb at the same time.

(1) Background: Peripheral artery disease (PAD) and related conditions significantly impair walking ability. Previous studies demonstrated that passive lightweight exosuits can improve walking biomechanics. However, most of these devices focus on assisting hip flexion. The aim of this study was to investigate the effects of flexion and extension assistance on joint kinetics and muscle activation. We hypothesized that there would be an optimal combination of flexion and extension assistance for measured parameters. (2) Methods: Four patients with PAD and six healthy individuals walked on a treadmill while wearing a passive exosuit with adjustable hip flexion and extension assistance. Lower limbs’ power, moment, and muscle activation were recorded. (3) Results: We found that passive hip assistance effectively reduced hip kinetics in both healthy and PAD participants. We also found different effects between the groups, with the PAD group utilizing the exosuit to reduce plantarflexion kinetics and gastrocnemius activity. (4) Conclusions: These findings suggest that patients with PAD can leverage the exosuit to ameliorate impairment-specific deficits. Future research should explore more real-world applicability of passive exosuits.

Shoes or insoles embedded with carbon fiber materials to increase longitudinal stiffness have been shown to enhance running and walking performance in elite runners, and younger adults, respectively. It is unclear, however, if such stiffness modifications can translate to enhanced mobility in older adults who typically walk with greater metabolic cost of transport compared to younger adults. Here, we sought to test whether adding footwear stiffness via carbon fiber insoles could improve walking outcomes (eg, distance traveled and metabolic cost of transport) in older adults during the 6-minute walk test. 20 older adults (10 M/10 F; 75.95 [6.01] y) performed 6-minute walk tests in 3 different shoe/insole stiffnesses (low, medium, and high) and their own footwear (4 total conditions). We also evaluated participants’ toe flexor strength and passive foot compliance to identify subject-specific factors that influence performance from added shoe/insole stiffnesses. We found no significant group differences in distance traveled or net metabolic cost of transport (P ≥ .171). However, weaker toe flexors were associated with greater improvement in distance traveled between the medium and low stiffness conditions (P = .033, r = −.478), indicating that individual foot characteristics may help identify potential candidates for interventions involving footwear stiffness modifications.

Introduction:Biomechanical changes due to aging increase the oxygen consumption of walking by over 30%. When this is coupled with reduced oxygen uptake capacity, the ability to sustain walking becomes compromised. This reduced physical activity and mobility can lead to further physical degeneration and mortality. Unfortunately, the underlying reasons for the increased metabolic cost are still inadequately understood. While motion capture systems can measure signals with high temporal resolution, it is impossible to directly characterize the fluctuation of metabolic cost throughout the gait cycle. Methods:To address this issue, this research focuses on computing the metabolic cost time series from the mean value using two neural-network-based approaches: autoencoders (AEs) and expanders. For the AEs, the encoders are designed to compress the input time series down to their mean value, and the decoder expands those values into the time series. After training, the decoder is extracted and applied to mean metabolic cost values to compute the time series. A second approach leverages an expander to map the mean values to the time series without an encoder. The networks are trained using ten different metabolic cost models generated by a computational walking model that simulates the gait cycle subjected to 35 different robotic perturbations without using experimental input data. The networks are validated using the estimated metabolic costs for the unperturbed gait cycle. Results:The investigation found that AEs without tied weights and the expanders performed best using nonlinear activation functions, while the AEs with tied weights performed best with linear activation functions. Unexpectedly, the results show that the expanders outperform the AEs. Discussion:A limitation of this research is the reliance on time series for the initial training. Future efforts will focus on developing methods that overcome this issue. Improved methods for estimating within-stride fluctuations in metabolic cost have the potential of improving rehabilitation and assistive devices by targeting the gait phases with increased metabolic cost. This research could also be applied to expand sparse measurements to locations or times that were not measured explicitly. This application would reduce the number of measurement points required to capture the response of a system.

Abstract Metabolic cost greatly impacts trade-offs within a variety of human movements. Standard respiratory measurements only obtain the mean cost of a movement cycle, preventing understanding of the contributions of different phases in, for example, walking. We present a method that estimates the within-stride cost of walking by leveraging measurements under different force perturbations. The method reproduces time series with greater consistency (r = 0.55 and 0.80 in two datasets) than previous model-based estimations (r = 0.29). This perturbation-based method reveals how the cost of push-off (10%) is much smaller than would be expected from positive mechanical work (~ 70%). This work elucidates the costliest phases during walking, offering new targets for assistive devices and rehabilitation strategies.

This study focused on designing and evaluating a bilateral semi-rigid hip exoskeleton. The exoskeleton assisted the hip joint, capitalizing on its proximity to the body’s center of mass. Unlike its rigid counterparts, the semi-rigid design permitted greater freedom of movement. A temporal force-tracking controller allowed us to prescribe torque profiles during walking. We ensured high accuracy by tuning control parameters and series elasticity. The evaluation involved experiments with ten participants across ten force profile conditions with different end-timings and peak magnitudes. Our findings revealed a trend of greater reductions in metabolic cost with assistance provided at later timings in stride and at greater magnitudes. Compared to walking with the exoskeleton powered off, the largest reduction in metabolic cost was 9.1%. This was achieved when providing assistance using an end-timing at 44.6% of the stride cycle and a peak magnitude of 0.11 Nm kg−1. None of the tested conditions reduced the metabolic cost compared to walking without the exoskeleton, highlighting the necessity for further enhancements, such as a lighter and more form-fitting design. The optimal end-timing aligns with findings from other soft hip exosuit devices, indicating a comparable interaction with this prototype to that observed in entirely soft exosuit prototypes.

Background: The most common symptom of peripheral artery disease (PAD) is intermittent claudication that involves the calf, thigh, and/or buttock muscles. How the specific location of this leg pain is related to altered gait, however, is unknown.Objectives: We hypothesized that because the location of claudication symptoms uniquely affects different leg muscle groups in people with PAD, this would produce distinctive walking patterns. Methods: A total of 105 participants with PAD and 35 age-matched older volunteers without PAD (CTRL) were recruited. Participants completed walking impairment questionnaires (WIQ), Gardner-Skinner progressive treadmill tests, the six-minute walk test, and we performed an advanced evaluation of the biomechanics of their overground walking. Participants with PAD were categorized into 4 groups according to their stated pain location(s): calf only (C, n = 43); thigh and calf (TC, n = 18); buttock and calf (BC, n = 15); or buttock, thigh, and calf (BTC, n = 29). Outcomes were compared between CTRL, C, TC, BC and BTC groups using a one-way ANOVA with post-hoc comparisons to identify and assess statistically significant differences.Results: There were no significant differences between CTRL, C, TC, BC and BTC groups in distances walked or walking speed when either pain-free or experiencing claudication pain. Each participant with PAD had significantly dysfunctional biomechanical gait parameters, even when pain-free, when compared to CTRL (pain -free) walking data. During pain-free walking, out of the 18 gait parameters evaluated, we only identified significant differences in hip power generation during push-off (in C and TC groups) and in knee power absorption during weight acceptance (in TC and BC groups). There were no between-group differences in gait parameters while people with PAD were walking with claudication pain.Conclusions: Our data demonstrate that PAD affects the ischemic lower extremities in a diffuse manner irrespective of the location of claudication symptoms.Database Registration: ClinicalTrials.gov NCT01970332.(c) 2023 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC -ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Peripheral artery disease (PAD) is characterized by reduced blood flow to the extremities due to atherosclerosis. Studies report impaired gait mechanics in patients with lower extremity PAD. We hypothesized that revascularization surgery would improve gait mechanics when quantified by net lower limb joint work across the stance phase of walking. We performed gait analyses in 35 patients with PAD and 35 healthy, older adults. Patients with PAD performed a walking protocol prior to and six months following revascularization surgery. Healthy adults only took part in a single walking session. Lower limb joint powers were calculated using inverse dynamics and were integrated across early, middle, and late stance phases to determine the work performed during each phase (J kg(-1)). The work mechanical ratio between positive-producing and negative-producing phases of stance was calculated for each lower-limb joint. Self-selected walking speed significantly increased from 1.13 +/- 0.2 ms(-1) to 1.26 +/- 0.18 ms(-1) in patients following revascularization (p < 0.001). We observed a significant decrease in positive late stance work (p < 0.001) in conjunction with more negative work during early stance (p < 0.001) in patients following revascularization. Revascularization surgery led to faster walking without an increase in the ankle joint's mechanical ratio. Our results suggest faster walking was achieved via work done at the hip rather than the ankle. These findings suggest that additional therapies that facilitate the restoration of muscle, tissue, and nervous system damage caused by years of having reduced blood flow to the limbs might still be beneficial following revascularization.

Robotic rehabilitation has been shown to match the effects of conventional physical therapy on motor function for patients with neurological diseases. Rehabilitation robots have the potential to reduce therapists’ workload in time-intensive training programs as well as perform actions that are not replicable by human therapists. We investigated the effects of one such modality that cannot be achieved by a human therapist: assistance and resistance within the electromechanical delay between muscle activation and muscle contraction during arm extension. We found increased muscle activation when providing robotic assistance within this electromechanical delay. Assistance provided within this delay moves the participant’s arm quicker than their own muscle and increases the subsequent peak voluntary muscle activation compared to normal arm extension by 68.97 ± 80.05% ( SE = 0.021; p = 0.007). This is surprising since all previous literature shows that muscle activation either decreases or does not change when participants receive robotic assistance. As a consequence, traditional robotic rehabilitation incrementally reduces assistance as the patient improves to maintain levels of muscle activation which is suggested to be important for neuronal repair. The present result may enable therapists to no longer have to choose between providing assistance or increasing muscle activation. Instead, therapists may be able to provide assistance while also increasing muscle activation.

The most common symptom of peripheral artery disease (PAD) is intermittent claudication, which consists of debilitating leg pain during walking. In clinical settings, the presence of PAD is often noninvasively evaluated using the ankle-brachial index and imaging of the arterial supply. Furthermore, various questionnaires and functional tests are commonly used to measure the severity and negative effect of PAD on quality of life. However, these evaluations only provide information on vascular insufficiency and severity of the disease, but not regarding the complex mechanisms underlying walking impairments in patients with PAD. Biomechanical analyses using motion capture and ground reaction force measurements can provide insight into the underlying mechanisms to walking impairments in PAD. This review analyzes the application of biomechanics tools to identify gait impairments and their clinical implications on rehabilitation of patients with PAD. A total of 18 published journal articles focused on gait biomechanics in patients with PAD were studied. This narriative review shows that the gait of patients with PAD is impaired from the first steps that a patient takes and deteriorates further after the onset of claudication leg pain. These results point toward impaired muscle function across the ankle, knee, and hip joints during walking. Gait analysis helps understand the mechanisms operating in PAD and could also facilitate earlier diagnosis, better treatment, and slower progression of PAD.

Background Asymmetric walking gait impairs activities of daily living in neurological patient populations, increases their fall risk, and leads to comorbidities. Accessible, long-term rehabilitation methods are needed to help neurological patients restore symmetrical walking patterns. This study aimed to determine if a passive unilateral hip exosuit can modify an induced asymmetric walking gait pattern. We hypothesized that a passive hip exosuit would diminish initial- and post-split-belt treadmill walking after-effects in healthy young adults. Methods We divided 15 healthy young adults evenly between three experimental groups that each completed a baseline trial, an adaptation period with different interventions for each group, and a post-adaptation trial. To isolate the contribution of the exosuit we compared a group adapting to the exosuit and split-belt treadmill (Exo-Sb) to groups adapting to exosuit-only (Exo-only) and split-belt only (Sb-only) conditions. The independent variables step length, stance time, and swing time symmetry were analyzed across five timepoints (baseline, early- and late adaptation, and early- and late post-adaptation) using a 3 × 5 mixed ANOVA. Results We found significant interaction and time effects on step length, stance time and swing time symmetry. Sb-only produced increased step length asymmetry at early adaptation compared to baseline (p < 0.0001) and an after-effect with increased asymmetry at early post-adaptation compared to baseline (p < 0.0001). Exo-only increased step length asymmetry (in the opposite direction as Sb-only) at early adaptation compared to baseline (p = 0.0392) but did not influence the participants sufficiently to result in a post-effect. Exo-Sb produced similar changes in step length asymmetry in the same direction as Sb-only (p = 0.0014). However, in contrast to Sb-only there was no significant after-effect between early post-adaptation and baseline (p = 0.0885). Conclusion The passive exosuit successfully diminished asymmetrical step length after-effects induced by the split-belt treadmill in Exo-Sb. These results support the passive exosuit’s ability to alter walking gait patterns.

Introduction: Human-in-the-loop optimization algorithms have proven useful in optimizing complex interactive problems, such as the interaction between humans and robotic exoskeletons. Specifically, this methodology has been proven valid for reducing metabolic cost while wearing robotic exoskeletons. However, many prostheses and orthoses still consist of passive elements that require manual adjustments of settings.Methods: In the present study, we investigated if human-in-the-loop algorithms could guide faster manual adjustments in a procedure similar to fitting a prosthesis. Eight healthy participants wore a prosthesis simulator and walked on a treadmill at 0.8 ms−1 under 16 combinations of shoe heel height and pylon height. A human-in-the-loop optimization algorithm was used to find an optimal combination for reducing the loading rate on the limb contralateral to the prosthesis simulator. To evaluate the performance of the optimization algorithm, we used a convergence criterium. We evaluated the accuracy by comparing it against the optimum from a full sweep of all combinations.Results: In five out of the eight participants, the human-in-the-loop optimization reduced the time taken to find an optimal combination; however, in three participants, the human-in-the-loop optimization either converged by the last iteration or did not converge.Discussion: Findings from this study show that the human-in-the-loop methodology could be helpful in tasks that require manually adjusting an assistive device, such as optimizing an unpowered prosthesis. However, further research is needed to achieve robust performance and evaluate applicability in persons with amputation wearing an actual prosthesis.

The metabolic rate of walking can be reduced by applying a constant forward force at the center of mass. It has been shown that the metabolically optimal constant force magnitude minimizes propulsion ground reaction force at the expense of increased braking. This led to the hypothesis that selectively assisting propulsion could lead to greater benefits. We used a robotic waist tether to evaluate the effects of forward forces with different timings and magnitudes. Here, we show that it is possible to reduce the metabolic rate of healthy participants by 48% with a greater efficiency ratio of metabolic cost reduction per unit of net aiding work compared with other assistive robots. This result was obtained using a sinusoidal force profile with peak timing during the middle of the double support. The same timing could also reduce the metabolic rate in patients with peripheral artery disease. A model explains that the optimal force profile accelerates the center of mass into the inverted pendulum movement during single support. Contrary to the hypothesis, the optimal force timing did not entirely coincide with propulsion. Within the field of wearable robotics, there is a trend to use devices to mimic biological torque or force profiles. Such bioinspired actuation can have relevant benefits; however, our results demonstrate that this is not necessarily optimal for reducing metabolic rate.

Semi-rigid exoskeletons could combine some advantages of rigid and soft approaches. The purpose of this study was to investigate the effects of timing and magnitude of assistance from a semi-rigid hip exoskeleton. For ten participants, we tested ten conditions that were combinations of 5 different end-timings, ranging from 21% to 49%, and 2 different moment magnitudes ranging from 0.06 to 0.12 Nm.kg -1 . The participants walked in two reference conditions: a condition without actuation and a condition without the exoskeleton. A semi-rigid hip exoskeleton could alter metabolic rate. However, to produce a net assistive effect, it is necessary to design a lighter, more conforming device. In both actuation magnitude levels, the optimal end-timing was close to the maximum range, similar to findings from another study with human-in-the-loop optimization of a soft hip exosuit. This could indicate that the optimal timing with a semi-rigid device is not very different from a fully-soft prototype.

Introduction In most everyday activities, we head towards a specific goal by updating our choices for a more direct path. For instance, when navigating toward a tall building, we can constantly update our road selection to get there. However, there are specific clinical tasks where taking the direct path is more challenging. Clinical investigations of optimizing a prosthesis involve the assessment of multiple parameter settings through trial and error rather than goal-directed optimization. Human-in-the-loop optimization algorithms allow devices to directly change in response to physiological changes (i.e., metabolic cost) of the user [1]. This methodology has proven very useful in advancing the optimization of robotic exoskeletons [2]. However, to our knowledge, this method has not yet been used for applications that involve manual alterations to a device. We investigate if a human-in-the-loop optimization algorithm can guide manual alterations to a prosthesis-simulating device to reduce the ground reaction force on the contralateral limb [3]. We hypothesized that the optimal parameter setting would reduce the loading rate on the contralateral limb compared to the initial tested parameter setting. If effective, this method could reduce the time taken for prosthetic fitting consultations.

An exoskeletal device can assist walking in those with gait deficits. A passive exoskeleton can be a favorable choice for local or home rehabilitation settings because it is affordable, light weight, and less complex to utilize. While there is research that investigates the effects of exoskeleton on gait research examining the effects of such devices on gait adaptation, is rare. This is important because in diseases like stroke, the ability to flexibly adapt is affected, such that functional recovery becomes difficult. The purpose of this study was to characterize gait adaptation patterns that result from exoskeleton usage during a split-belt adaptation task. Healthy young participants were randomly assigned to a unilateral exoskeleton or a no-exoskeleton group. Each participant performed the specific split-belt adaptation tasks on the treadmill, where the speed of each belt could be controlled independently. Symmetry indices of spatiotemporal variables were calculated to quantify gait adaptation. To analyze the adaptation, trials were divided into early and late adaptation. We also analyzed degree of adaptation, and transfer effects. We also measured the symmetry of the positive power generated by the individual legs during the split-belt task to determine if using exoskeleton assistance reduced power in the exoskeleton group versus the no-exoskeleton group. Use of a passive exoskeleton device altered gait adaptation during a split-belt treadmill task in comparison to the control group. Such adaptation was found to be largely restricted to the temporal domain. Changes in the gait coordination patterns consisted of both early and late adaptive changes, especially in intra-limb patterns like stance time rather than inter-limb patterns like step time. Although the symmetry of the positive power generated during the split-belt task was found to be reduced for the exoskeleton-assistance group, it was shown that this was primarily the result of increased positive power generated by the side not receiving exoskeletal assistance. An unpowered assistive device can provide a unique solution for coordinating the lower limbs during different gait tasks. Such a solution could reduce the neural burden of adaptation consequently resulting in a reduction of the mechanical burden of walking during the bilateral gait coordination task. This may be useful for accelerating gait rehabilitation in different patient populations. However, balance control is important to consider during unilateral exoskeletal assistance.

Purpose: Falls are one of the main causes of injuries in older adults. This study evaluated a low-cost footswitch device that was designed to measure gait variability and investigates whether there are any relationships between variability metrics and clinical balance tests for individuals with a history of previous falls. Methods: Sixteen older adults completed a history of falls questionnaire, three functional tests related to fall risk, and walked on a treadmill with the footswitch device. We extracted the stride times from the device and applied two nonlinear variability analyses: coefficient of variation and detrended fluctuation analysis. Results: The temporal variables and variability metrics from the footswitch device correlated with gold-standard measurements based on ground reaction force data. One variability metric (detrended fluctuation analysis) showed a significant relationship with the presence of past falls with a sensitivity of 43%. Conclusion: This feasibility study demonstrates the basis for using low-cost footswitch devices to predict fall risk.

Walking on different grades becomes challenging on energetic and muscular levels compared to level walking. While it is not possible to eliminate the cost of raising or lowering the centre of mass (COM), it could be possible to minimize the cost of distal joints with shoes that offset downhill or uphill grades. We investigated the effects of shoe outsole geometry in 10 participants walking at 1 m s −1 on downhill, level and uphill grades. Level shoes minimized metabolic rate during level walking ( P second-order effect < 0.001). However, shoes that entirely offset the (overall) treadmill grade did not minimize the metabolic rate of walking on grades: shoes with a +3° (upward) inclination minimized metabolic rate during downhill walking on a −6° grade, and shoes with a −3° (downward) inclination minimized metabolic rate during uphill walking on a +6° grade ( P interaction effect = 0.023). Shoe inclination influenced (distal) ankle joint parameters, including soleus muscle activity, ankle moment and work rate, whereas treadmill grade influenced (whole-body) ground reaction force and COM work rate as well as (distal) ankle joint parameters including tibialis anterior and plantarflexor muscle activity, ankle moment and work rate. Similar modular footwear could be used to minimize joint loads or assist with walking on rolling terrain.