Gait Rehabilitation System Research Articles

Human-centered design of a novel soft exosuit for post-stroke gait rehabilitation

BackgroundStroke remains a major cause of long-term adult disability in the United States, necessitating the need for effective rehabilitation strategies for post-stroke gait impairments. Despite advancements in post-stroke care, existing rehabilitation often falls short, prompting the development of devices like robots and exoskeletons. However, these technologies often lack crucial input from end-users, such as clinicians, patients, and caregivers, hindering their clinical utility. Employing a human-centered design approach can enhance the design process and address user-specific needs.ObjectiveTo establish a proof-of-concept of the human-centered design approach by refining the NewGait® exosuit device for post-stroke gait rehabilitation.MethodsUsing iterative design sprints, the research focused on understanding the perspectives of clinicians, stroke survivors, and caregivers. Two design sprints were conducted, including empathy interviews at the beginning of the design sprint to integrate end-users’ insights. After each design sprint, the NewGait device underwent refinements based on emerging issues and recommendations. The final prototype underwent mechanical testing for durability, biomechanical simulation testing for clinical feasibility, and a system usability evaluation, where the new stroke-specific NewGait device was compared with the original NewGait device and a commercial product, Theratogs®.ResultsAffinity mapping from the design sprints identified crucial categories for stakeholder adoption, including fit for females, ease of donning and doffing, and usability during barefoot walking. To address these issues, a system redesign was implemented within weeks, incorporating features like a loop-backed neoprene, a novel closure mechanism for the shoulder harness, and a hook-and-loop design for the waist belt. Additional improvements included reconstructing anchors with rigid hook materials and replacing latex elastic bands with non-latex silicone-based bands for enhanced durability. Further, changes to the dorsiflexion anchor were made to allow for barefoot walking. Mechanical testing revealed a remarkable 10-fold increase in durability, enduring 500,000 cycles without notable degradation. Biomechanical simulation established the modularity of the NewGait device and indicated that it could be configured to assist or resist different muscles during walking. Usability testing indicated superior performance of the stroke-specific NewGait device, scoring 84.3 on the system usability scale compared to 62.7 for the original NewGait device and 46.9 for Theratogs.ConclusionThis study successfully establishes the proof-of-concept for a human-centered design approach using design sprints to rapidly develop a stroke-specific gait rehabilitation system. Future research should focus on evaluating the clinical efficacy and effectiveness of the NewGait device for post-stroke rehabilitation.

Sonification for Personalised Gait Intervention.

Mobility challenges threaten physical independence and good quality of life. Often, mobility can be improved through gait rehabilitation and specifically the use of cueing through prescribed auditory, visual, and/or tactile cues. Each has shown use to rectify abnormal gait patterns, improving mobility. Yet, a limitation remains, i.e., long-term engagement with cueing modalities. A paradigm shift towards personalised cueing approaches, considering an individual's unique physiological condition, may bring a contemporary approach to ensure longitudinal and continuous engagement. Sonification could be a useful auditory cueing technique when integrated within personalised approaches to gait rehabilitation systems. Previously, sonification demonstrated encouraging results, notably in reducing freezing-of-gait, mitigating spatial variability, and bolstering gait consistency in people with Parkinson's disease (PD). Specifically, sonification through the manipulation of acoustic features paired with the application of advanced audio processing techniques (e.g., time-stretching) enable auditory cueing interventions to be tailored and enhanced. These methods used in conjunction optimize gait characteristics and subsequently improve mobility, enhancing the effectiveness of the intervention. The aim of this narrative review is to further understand and unlock the potential of sonification as a pivotal tool in auditory cueing for gait rehabilitation, while highlighting that continued clinical research is needed to ensure comfort and desirability of use.

Mobility Rehab visual feedback system for gait rehabilitation in older adults

BackgroundGait and balance impairments are among the main causes of falls in older adults. The feasibility and effectiveness of adding sensor-based feedback to physical therapy (PT) in an outpatient PT setting is unknown. We evaluated the feasibility and effectiveness of PT intervention combined with a therapist-assisted visual feedback system, called Mobility Rehab, (PT + MR) in older adults.MethodsTwenty-eight older adults with and without neurological diseases were assigned either PT + MR (n = 22) or PT alone (n = 6). Both groups performed 8 sessions (individualized) of 45 min long (30 min for gait training and 15 min for endurance, strength, and balance exercises) in an outpatient clinic. Mobility Rehab uses unobtrusive, inertial sensors on both wrists and feet, and at the sternum level with real-time algorithms to provide real-time feedback on five gait metrics (step duration, stride length, elevation at mid-swing, arm swing range-of-motion [ROM], and trunk coronal ROM), which are displayed on a tablet. The primary outcome was the Activities-specific Balance Confidence scale (ABC). The secondary outcome was gait speed measured with wearable inertial sensors during 2 min of walking.ResultsThere were no between-group differences at baseline for any variable (P > 0.05). Neither PT + MR nor PT alone showed significant changes on the ABC scores. PT + MR, but not PT alone, showed significant improvements in gait speed and arm swing ROM. The system was evaluated as ‘easy to use’ by the PT.ConclusionsOur preliminary results show that PT + MR improves gait speed in older adults with and without neurological diseases in an outpatient clinic.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier: NCT03869879.

A VR-based Treadmill Training System for Post-stroke Gait Rehabilitation.

Virtual reality (VR) has the potential to enhance rehabilitation by creating simulated multiple training environments, thereby maximizing the implementation of motor learning principles. However, previous use of VR-based treadmill training to improve post-stroke gait function is limited by high cost and a lack of adherence to post-stroke gait rehabilitation principles in system design. This paper describes the development of a gait rehabilitation system that integrates treadmill gait training with VR technology to create a virtual rehabilitation setting with gait training tasks and real-time performance feedback. The proposed system targets post-stroke patients and integrates low-cost sensor and rehabilitation principles to allow remote training and maximize training efficacy.Clinical Relevance-This system is developed with an emphasis on rehabilitation and motor learning principles.

Development of a novel body weight support system for gait rehabilitation

AbstractModern rehabilitation processes for neurological patients have been widely assisted by robotic structures, with continuous research and improvements. The use of robotic assistance in rehabilitation is a consolidated technique for upper limb training sessions. However, human gait robotic rehabilitation still needs further research and development. Based on that, this paper deals with the development of a novel active body weight support (BWS) system integrated with a serious game for poststroke patients. This paper starts with a brief review of the state of the art of applied technologies for gait rehabilitation. Next, it presents the obtained mathematical model followed by multibody synthesis techniques and meta-heuristic optimization to the proposed device. The control of the structure is designed using proportional integral derivative (PID) controllers tuned with meta-heuristic optimization and associated with a suppression function to perform assist-as-needed actions. Then, the prototype is integrated with a serious game designed specifically for this application. Finally, a pilot study is conducted with the structure and healthy volunteers. The results obtained show that the mobility of the novel BWS is as expected and the proposed system potentially offers a novel tool for gait training.

Relationships between Body Weight Support and Gait Speed Parameters and Muscle Activity and Torque during Robot-Assisted Gait Training in Non-Neurological Adults: A Preliminary Investigation

Robot-assisted gait training (RAGT) is a promising therapeutic vehicle to maximize active participation and enhance functional neuroplasticity in patients with central nervous system pathology by adequately adjusting gait speed, body weight support (BWS) level, and impedance provided by the exoskeleton. The aim of the present study was to determine the relationship between RAGT training parameters (BWS and speed) and electromyography (EMG) muscle activity torques in the knee and hip joint during RAGT. To analyze the correlation between the joint torques measured in the Walkbot gait rehabilitation system and the EMG signal of the lower limbs (vastus lateralis oblique, biceps femoris, tibialis anterior, and gastrocnemius) and understand the real-time state of the lower limb an experiment involving 20 subjects was conducted. The EMG–torque relationship was evaluated in a general rehabilitation training setting to overcome the limitations of in vivo settings. Pearson correlation coefficient analysis was performed at p < 0.05. Moderate relationships between biceps femoris activation data and hip and knee torques were statistically significant, ranging from r = 0.412 to −0.590, p < 0.05). Importantly, inverse relationships existed between hip torques and vastus lateralis oblique, biceps femoris, and tibialis anterior activation, respectively. The present results demonstrated the association between EMG locomotor control patterns and torque generation in the hip and knee joints during RAGT-treadmill under the different BWS and walking speed settings while adjusting the impedance mode parameters in non-neurological adults. Additionally, the EMG locomotor control patterns, concurrent torque generation in the hip and knee joints, and application of different BWS and walking speed parameters in the RAGT were linked to the gait speed and BWS. The outcomes also showed that the amount of BWS supplied had an impact on the effects of treadmill speed on muscle activity and temporal step control. It is essential to adjust RAGT parameters precisely in order to maximize training session efficiency and quality. The results of this study nevertheless call for more investigation into the relationship between muscle activity and torque outcomes in diseased populations with gait impairment.

Integration of persuasive elements into exergames: Application in the development of a novel gait rehabilitation system for children with musculoskeletal conditions

The main contribution of this paper is the application of the Persuasive System Design (PSD) model for the analysis and development of exergame systems to stimulate pediatric patients to adhere to short-term gait rehabilitation. It resulted in a novel therapy consisting of a video gaming and virtual reality (VG/VR) biofeedback system for treadmill gait rehabilitation, including a method for progressing the rehabilitation settings. During gait rehabilitation (GR) sessions, therapy settings need to be adjusted by physiotherapists, based on their clinical experience, to address the deficiencies of individuals while maximizing their motor functioning and maintaining their motivation. The system integrates persuasive elements, adjusted when physiotherapists progress the therapeutic settings, such as the treadmill speed, auditory feedback, and game challenges. We followed a scenario-based design method to develop the system, which comprised an observational study of conventional GR sessions and evaluations with 6 and 9 rehabilitation specialists who provided feedback about the system design. They perceived that the proposed method was valuable for physiotherapists to adapt the rehabilitation based on the children’s performance. Also, they remarked that the system’s visual and auditory stimulus would help engage the children in the therapy.

Development of a Prototype Overground Pelvic Obliquity Support Robot for Rehabilitation of Hemiplegia Gait.

In this work, we present the overground prototype gait-rehabilitation robot for using motion assistance and training for paralyzed patients. In contrast to the existing gait-rehabilitation robots, which focus on the sagittal plane motion of the hip and knee, we aim to develop a mobile-based pelvic support gait-rehabilitation system that includes a pelvic obliquity support mechanism and a lower-limb exoskeleton. To achieve this, a scissor mechanism is proposed to generate the paralyzed patient’s pelvic obliquity motion and weight support. Moreover, the lower limb exoskeleton robot is integrated with the developed system to provide the patient’s gait by correcting mechanical aids. We used computer-aided analysis to verify the performance of the prototype hardware itself. Through these methods, it was shown that our motor can sufficiently lift 100 kg of user weight through the scissor mechanism, and that the mobile driving wheel motor can operate at a speed of 1.6 m/s of human walking, showing that it can be used for gait rehabilitation of patients in need of a lower speed. In addition, we verified that the system drives the model by generating pelvic motion, and we verified the position controller of the integrated system, which supports the multi-degree motion by creating hip/knee/pelvic motion with a human dummy mannequin and systems. We believe that the proposed system can help address the complex rehabilitation motion assistance and training of paralyzed patients.

Singularity Analysis of a Hybrid Serial-Cable Driven Planar Robot

Inthis study, we address the problem of singularities of a hybrid serial-cabledriven planar robot. Based on an analytical kinetostatic analysis three typesof singularities are determined, i.e., serial, parallel, and combinedsingularities. In addition, cable tensions should be positive, otherwise, therobot will be uncontrollable. The serial singularity corresponds to positionswhere the serial port of the robot is fully extended or fully folded. Theparallel singularity corresponds to aligned cables and combined singularitiescorrespond to both cases. Cable tensions distribution, within the workspace, isdetermined, which allowed the identification of regions where the cabletensions exceed an allowable value. The influence of physical parameters on theworkspace of the robot and its singular configurations is also studied. Anexample of a gait rehabilitation system using this type of robot is shown.Based on the kinetostatic analysis, multi-objective optimization of thedexterity and the cable tensions is performed, which yielded solutionsrepresented by a Pareto front. The results have been extended to the case of 3degrees of freedom hybrid robot.

Gait Rehabilitation and Locomotion Support System Using a Distributed Controlled Robot System

In this paper, we proposed a distributed controlled gait rehabilitation and locomotion support system through human-robot cooperative control, and combination of two cane-type walking support robots (left and right) and one wheelchair robot to support the walking and locomotion of a person in need of walking assistance. The proposed system can realize five types of motion support from gait training to daily motion support, using three types of motion support modes with a distributed robot control system comprising up to three robots to support the user’s independence for walking and moving. The cane-type walking support robot moved in response to the manipulation force applied to the robot by the user, and can realize walking/movement support in all directions through the omnidirectional traveling part. In addition, the height of the robot can be adjusted according to the user’s physique, and the motion characteristics can be set according to the user’s walking ability. The wheelchair robot has a seat that can be raised, lowered, and tilted to provide standing assistance for the user and mobility support as an electric wheelchair. In this study, we developed a prototype of the proposed system and demonstrated its feasibility for five types of assistive actions in experiments with healthy subjects.

A robotic system for gait rehabilitation: nonlinear modelling and evaluation

A robotic system for gait rehabilitation: nonlinear modelling and evaluation

A Mobile Cable-Tensioning Platform to Improve Crouch Gait in Children With Cerebral Palsy.

Gait impairment represented by crouch gait is the main cause of decreases in the quality of lives of children with cerebral palsy. Various robotic rehabilitation interventions have been used to improve gait abnormalities in the sagittal plane of children with cerebral palsy, such as excessive flexion in the hip and knee joints, yet in few studies have postural improvements in the coronal plane been observed. The aim of this study was to design and validate a gait rehabilitation system using a new cable-driven mechanism applying assist in the coronal plane. We developed a mobile cable-tensioning platform that can control the magnitude and direction of the tension vector applied at the knee joints during treadmill walking, while minimizing the inertia of the worn part of the device for less obstructing the natural movement of the lower limbs. To validate the effectiveness of the proposed system, three different treadmill walking conditions were performed by four children with cerebral palsy. The experimental results showed that the system reduced hip adduction angle by an average of 4.57 ± 1.79° compared to unassisted walking. Importantly, we also observed improvements of hip joint kinematics in the sagittal plane, indicating that crouch gait can be improved by postural correction in the coronal plane. The device also improved anterior and lateral pelvic tilts during treadmill walking. The proposed cable-tensioning platform can be used as a rehabilitation system for crouch gait, and more specifically, for correcting gait posture with minimal disturbance to the voluntary movement.

Investigation of optimal gait speed for motor learning of walking using the vibro-tactile biofeedback system.

In stroke patients, sensory loss often reduces the sensation of ground contact, which impairs motor learning during rehabilitation. In our previous study, we proposed a vibro-tactile biofeedback system (which we called the perception-empathy biofeedback system) for gait rehabilitation. The results of our 9-week pilot clinical test suggested that patients who had reached the autonomous phase in gait learning had difficulty noticing the external vibratory feedback provided by the biofeedback system, leading to ineffective intervention. We considered the possibility that slower walking speed might return the patient to the association phase and allow patients to improve their gait according to the sensory feedback provided. Thus, in this research, a method based on reducing walking speed to guide patients' attention was derived. A pilot clinical trial shows that there is a statistically significant increase of ankle dorsiflexion in the initial contact phase and increase of ankle plantarflexion in the push-off phase after vibro-tactile biofeedback system intervention with speed reduction, compared to intervention without speed reduction. The results suggest that, by reducing their walking speed during intervention, patients return to the association phase and recognize external vibratory feedback, which may result in better intervention effects.Clinical Relevance-This study provides knowledge about the optimal walking speed when using vibro-tactile biofeedback for motor learning in stroke patients.

Development of a vibrotactile cueing device that implicitly increases walking speed during gait training in stroke patients: an observational case series study

One of the main sequelae of stroke is difficulty walking, which is characterised by decreased walking speed and asymmetrical walking patterns. Physical therapists often rely on explicit motor learning strategies, i.e., providing mainly verbal instructions for how movements should be performed. However, the voluntary movement induced by explicit instruction may lead to associated unintended muscle contractions or higher cognitive demand, which could be detrimental. We introduce a vibrotactile cueing device that implicitly improves walking speed. The stroke patient walks while alternating vibrational cues are given to the left and right sides of their waist. At each specified step, cueing frequency increases in the cueing group without the patient’s awareness. The four patients in the cueing group did not notice the increase in walking speed during training; however, we observed an improvement in walking speed and cadence in patients using the proposed cueing system, which was maintained during the posttest phase. Additionally, patients using the cueing system were able to suppress excessive compensatory movements during training compared with patients who did not use the system. This case series study indicates that the proposed system for gait rehabilitation of stroke patients can enable an increase in walking speed without excessive effort.

Immersive virtual reality during gait rehabilitation increases walking speed and motivation: a usability evaluation with healthy participants and patients with multiple sclerosis and stroke

BackgroundThe rehabilitation of gait disorders in patients with multiple sclerosis (MS) and stroke is often based on conventional treadmill training. Virtual reality (VR)-based treadmill training can increase motivation and improve therapy outcomes. The present study evaluated an immersive virtual reality application (using a head-mounted display, HMD) for gait rehabilitation with patients to (1) demonstrate its feasibility and acceptance and to (2) compare its short-term effects to a semi-immersive presentation (using a monitor) and a conventional treadmill training without VR to assess the usability of both systems and estimate the effects on walking speed and motivation.MethodsIn a within-subjects study design, 36 healthy participants and 14 persons with MS or stroke participated in each of the three experimental conditions (VR via HMD, VR via monitor, treadmill training without VR).ResultsFor both groups, the walking speed in the HMD condition was higher than in treadmill training without VR and in the monitor condition. Healthy participants reported a higher motivation after the HMD condition as compared with the other conditions. Importantly, no side effects in the sense of simulator sickness occurred and usability ratings were high. No increases in heart rate were observed following the VR conditions. Presence ratings were higher for the HMD condition compared with the monitor condition for both user groups. Most of the healthy study participants (89%) and patients (71%) preferred the HMD-based training among the three conditions and most patients could imagine using it more frequently.ConclusionsFor the first time, the present study evaluated the usability of an immersive VR system for gait rehabilitation in a direct comparison with a semi-immersive system and a conventional training without VR with healthy participants and patients. The study demonstrated the feasibility of combining a treadmill training with immersive VR. Due to its high usability and low side effects, it might be particularly suited for patients to improve training motivation and training outcome e. g. the walking speed compared with treadmill training using no or only semi-immersive VR. Immersive VR systems still require specific technical setup procedures. This should be taken into account for specific clinical use-cases during a cost–benefit assessment.

Pelvis mobility control solutions for gait rehabilitation systems: a review

Pelvis mobility control solutions for gait rehabilitation systems: a review

Biomechanical Analysis in Five Bar Linkage Prototype Machine of Gait Training and Rehabilitation by IMU Sensor and Electromyography.

The prototype machine of gait training and rehabilitation (MGTR) with a five-bar linkage structure was designed to improve the common end-effector type. Additionally, the study was conducted to evaluate the joint angle and muscle activity during walking for the evaluation of prototype: (1) Background: The gait rehabilitation systems are largely divided into exoskeletal type and end-effector type. The end-effector type can be improved a gait trajectory similar to normal gait according to this prototype. Therefore, a new design of prototype MGTR is proposed in this study. (2) Methods: The gait experience was conducted with thirteen healthy male subjects using an inertial measurement unit (IMU) sensor and electromyography (EMG). It was compared that the hip and knee joints and the muscle activity between the normal gait and MGTR. (3) Results: The results showed that there was a high correlation between the knee joint angle for normal gait and MGTR. The range of motion (RoM) was small for the MGTR. The EMG results showed that the activation of the rectus femoris muscle was most similar to the normal gait and MGTR. (4) Conclusions: The characteristics of the kinematic variables of the subjects varied widely. It is necessary to modify the machine so that the link length can be adjusted in consideration of various segment lengths of patients.

Towards Neuro-Fuzzy Compensated PID Control of Lower Extremity Exoskeleton System for Passive Gait Rehabilitation

The objective of this work is to design a neuro-fuzzy compensated PID control for passive gait rehabilitation using a lower extremity exoskeleton system. A prototype of 6-DOFs exoskeleton device is developed to assist the children of age 8–10 years old. A dummy having a well-matched body attributes to a healthy child (10 years) is utilized in this work to carry out the experimental runs. Kinect-LabVIEW setup is employed to compute the desired joint angles in the sagittal plane for a healthy gait trajectory. The Euler–Lagrange method is utilized to formulate the dynamic analysis of the exoskeleton system. As the performance of existing control strategies for gait rehabilitation devices is still debatable; therefore, a robust neuro-fuzzy compensated PID control strategy is designed in this work. The asymptotic stability of the proposed control scheme is proved mathematically by Lyapunov theorem. Thereafter, the proposed control strategy is implemented on the exoskeleton-dummy setup in real-time and compared with the classical PID control strategy. From experimental runs, the root mean square error (RMSE) for proposed control scheme is found to be less by 40% nearly while tracking the desired gait trajectory. The robustness of the proposed controller is also validated by varying lower limb masses of dummy and by providing an external disturbance. It is observed that proposed controller is more robust to deal with the input disturbance as compared to parametric uncertainty. Finally, the low values of settling time in both the directions ensures the fast convergence of proposed controller.

Rehabilitative training system based on a ceiling rail for detecting the intended movement direction of a user.

BACKGROUND:Accurate detection of the intended movement direction of a patient plays an important role in the development of a training system for gait rehabilitation and enables to increase the effect of gait rehabilitation training.OBJECTIVE: This study investigated the detection of the intended movement of a user to operate a ceiling rail-based rehabilitative training system with accurate timing.METHODS: To detect the movement direction intention of a user, two potentiometers were used to measure the movement direction in the anterior, posterior, and left and right directions of the user when operating the driving motor of the rehabilitative training system. A simple test mock-up with two potentiometers was fabricated, and the experiments were conducted to determine the effect of the direction of movement on the measured values of potentiometers. A direction measurement algorithm was developed to control the driving motor of the rail-based gait rehabilitative training system.RESULTS: The intended movement direction of the user could be predicted for eight directions by combining the “positive value, 0, negative value” of each measured value of the two potentiometers. Further, the developed algorithm was effectively used to control the driving function to assist the walking, sitting–standing, and climbing up–down the step activities in daily life.CONCLUSIONS: The movement intention detection function for users developed in this paper can be used to effectively control a rehabilitative training system for patients with hemiplegia to improve gait movement and posture balance, thereby improving their function of activities of daily living.

Progressive Modular Rebalancing System and Visual Cueing for Gait Rehabilitation in Parkinson's Disease: A Pilot, Randomized, Controlled Trial With Crossover.

Introduction: The progressive modular rebalancing (PMR) system is a comprehensive rehabilitation approach derived from proprioceptive neuromuscular facilitation principles. PMR training encourages focus on trunk and proximal muscle function through direct perception, strength, and stretching exercises and emphasizes bi-articular muscle function in the improvement of gait performance. Sensory cueing, such as visual cues (VC), is one of the more established techniques for gait rehabilitation in PD. In this study, we propose PMR combined with VC for improving gait performance, balance, and trunk control during gait in patients with PD. Our assumption herein was that the effect of VC may add to improved motor performance induced by the PMR treatment. The primary aim of this study was to evaluate whether the PMR system plus VC was a more effective treatment option than standard physiotherapy in improving gait function in patients with PD. The secondary aim of the study was to evaluate the effect of this treatment on motor function severity.Design: Two-center, randomized, controlled, observer-blind, crossover study with a 4-month washout period.Participants: Forty individuals with idiopathic PD in Hoehn and Yahr stages 1–4.Intervention: Eight-week rehabilitation programs consisting of PMR plus VC (treatment A) and conventional physiotherapy (treatment B).Primary outcome measures: Spatiotemporal gait parameters, joint kinematics, and trunk kinematics.Secondary outcome measures: UPDRS-III scale scores.Results: The rehabilitation program was well-tolerated by individuals with PD and most participants showed improvements in gait variables and UPDRS-III scores with both treatments. However, patients who received PMR with VC showed better results in gait function with regard to gait performance (increased step length, gait speed, and joint kinematics), gait balance (increased step width and double support duration), and trunk control (increased trunk motion) than those receiving conventional physiotherapy. While crossover results revealed some differences in primary outcomes, only 37.5% of patients crossed over between the groups. As a result, our findings should be interpreted cautiously.Conclusions: The PMR plus VC program could be used to improve gait function and severity motor of motor deficit in individuals with PD.Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03346265.