Exoskeletons for Rehabilitation in Motor Impairments

Oscar I. Caldas1, Oscar F. Avilés2, Mauricio Mauledoux3

DAVINCI Research Group, Universidad Militar Nueva Granada, Cr 11 No 101-

80, Bogotá – Colombia.
e-mail: oscar.caldas@unimilitar.edu.co, 2oscar.aviles@unimilitar.edu.co
1
3
mauricio.mauledoux@unimilitar.edu.co
Orcid: 0000-0002-3105-4656, 20000-0002-9964-947X, 30000-0001-8676-9926
1

Abstract
This article discusses the technological advances made in the field of exoskeletons
(wearable or fixed robots) for motor rehabilitation of motor disorders. Different studies
were screened to identify the main trends in sensors and actuators selection, most suitable
control strategies and mechanical designs, but also to point out the target populations for
both upper and lower limb motor rehabilitation. Since robotic exoskeletons support the
recovery of motor skills by intensive training on different joints, the different robotic
configurations are analyzed to clarify the needs and the methods used for treatments related
motions and paths following, such as those to allow abduction / adduction, flexion /
extension, elevation / depression, external / internal rotation, among others, as well as to
other degrees of freedom over the sagittal, frontal and transverse planes. This overview
also considers the different uses of the robotic devices to overcome force and range of
motion limitations, tremor suppression, muscle weakness rehabilitation, diagnosis of
abnormal stiffness on motion, and mostly to improve motor function. Most of upper-limb
exoskeletons showed to focus on neuromuscular disorders, whereas lower-limb
exoskeletons are usually designed for body-weight support and treatment of chronic motor
diseases. Based on the insights extracted in this overview, the design and subsequent
implementation of external devices or robotic exoskeletons are analyzed, in order to obtain
a more solid base of knowledge for future developments.

Keywords: Locomotion, Rehabilitation robotics, Exoskeletons and Motion analysis

1. Introduction
Quality of life can be significantly affected due to motion disorders, either by limiting
the capability to perform basic activities of daily living (ADL), usually depending on the
upper limbs, or by reducing mobility and autonomy via problems in the lower limbs [1].
Stroke is by far the major cause of adult disability and consumes 2-4 % of the worldwide
healthcare costs [2]. Moreover, approximately 90% of stroke survivors have compromised
functions and thus it was declared as the sixth most common cause of life-years lost due to
disability [3]. Survivors use to suffer paralysis or loss of physical strength on one side of
the body, known as hemiparesis, at both upper and lower limbs, and therefore rehabilitation
is focus on task-based therapies that promote relearning in the motor use of musculoskeletal
system, i.e. learn to move again to recover independence.
According to [4], therapies can be performed by stroke survivors throughout most of
their life, which could be labor intensive and costly, and thus some factors contributing to
a faster motor recovery must be addressed, including therapies performed soon after stroke,
intensive therapy, task-based exercises and higher repetitions [5], [6].
Cerebral palsy (CP) is, on the other hand, the most common brain-damage disorder in
children affecting the motor system permanently, normally reported as poor coordination
and balance, abnormal motion patterns or a combination of those, depending on the
pathology presented [1]. Although 70-80% cases are acquired during the prenatal period

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 due to congenital but unknown causes, some neonatal risk factors have been identified:
prematurity, low birthweight, intracranial hemorrhage, intrauterine growth retardation, and
trauma, whereas 10-20% of patients could acquire it postnatally due to brain damage
associated with bacterial or viral inflammations, elevated levels of bilirubin, falls, vehicle
collisions, or child abuse [2]. The classification varies relying on the side of body (unilateral
or bilateral), on the body parts (hemiplegia, diplegia or quadriplegia) or on the type of
motion, i.e. either spastic (too much muscle tone), athetoid (uncontrolled movements),
hypotonic (not enough muscle tone), ataxic (balance and coordination problems) or mixed
(two or more).
In any case, the population of stroke and cerebral palsy continues to grow (the latest due
to better chances of survival after birth) and providing rehabilitation to patients becomes
more difficult every day. Hence, exoskeletons appear as a promising approach to meet the
demand, since they can provide intensive treatments for a longer duration and regardless of
the skills or fatigue of the healthcare provider and therapist [7].
This paper gives a brief overview of the current state of the exoskeletons used for
research, rehabilitation, and clinical interventions, focused on patients with motor
impairments due to neuromuscular disorders. The literature search was done mainly in
IEEE Xplore, but other databases we also considered.

2. 2. General biomechanical terms for upper and lower limbs

According to a pediatric point of view, when working with neuromuscular disorders, the
rehabilitation approaches could be for function restoration and/or environmental adaptation
[8]. Remediation techniques not only focus on restoring the joint’s range of motion, but
also on muscle strength and tone, sensory enhancement, postural control, motor learning,
etc. Compensatory techniques, however, consider the uses of orthoses to help on activities
of daily living, such as standing, walking, dressing, feeding, writing and grooming [9].
Upper and lower limbs are responsible for different locomotor functions, mainly for
moving from one point to another, as well as for additional functions such as jumping,
spinning, static equilibrium, balancing, dodging, etc. [10].
On one side, the upper limb is formed by each of the links fixed to the upper body by
successive joints: a) the sternoclavicular joint allowing 2 degrees of freedom (DOF) in the
neck, known as shoulder elevation/depression and retraction/protraction; b) the
glenohumeral joint at the shoulder joint has 3: flexion/extension, abduction/adduction and
internal/external rotation; c) a hinge in the elbow for flexion/extension; and d)
flexion/extension and deviation in the wrist; plus, the relative rotation of the radius around
the ulna is known as forearm pronation/supination. It is important to point out that during
arm abduction above the horizontal plane there is also a shoulder elevation [11].
Similarly, the lower limb is formed by 3 joints: the knee joint allows flexion/extension,
whereas the hip has the same 3 degrees of freedom than the shoulder, and the ankle allows
dorsiflexion/plantar-flexion and inversion/eversion [5].
These are synovial joints (also called diarthrosis) and are key for being capable of
developing large motions. According to generally accepted classification described by [6],
among such joints there are the following configurations: a) Hinge joints, which refer to
synovial joints where the joint surfaces have flexion and extension (e.g. elbow); b) Plane
joints, allowing only sliding or gliding motions between the flat surfaces (e.g.
acromioclavicular joint); c) Pivot joints, they allow relative rotations (e.g. neck and elbow);
d) Ball and socket joints, with free motions in any direction, such as the hip and shoulder;
e) Saddle joints, where two surfaces are reciprocally concave/convex, such as in the first
metacarpal bone and carpal; and f) ellipsoidal joints, also called condyloid joints, where
two bones are joined and irregularly shaped similar to the ball and socket joint (e.g. wrist).

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 There also compound or bicondyloid joints, such as the knee, where there is a combination
of condylar and saddle joints.
Regarding to the muscles, it is key to note that motion occurs only in contraction, and
thus an opposing contraction appears to control that motion by means of compensation.
This agonist/antagonist pair of muscles activity can be seen in all joints, such as the biceps
brachii to flex the and the triceps brachii to extend it [12]. Moreover, the dynamics of such
joint rotation depends on the location of the muscles attachment, as described by [13]: if
muscle origin is far from the joint but inserted close to it, the contraction would describe a
fast joint rotation with a low torque and it is called a spurt muscle, but on the contrary, if
the origin is close to the joint and the insertion is far from it, the called shunt muscle
produces larger moments with a slower rotation. In the elbow flexion, biceps and brachialis
are the spurt muscles whereas the brachioradialis acts as the shunt muscle.

3. Exoskeletons for Joint Motion Rehabilitation

It is now well established from a variety of studies that exoskeletons play an important
role in rehabilitation and mobility of joints by contributing on both generating and
supporting motion for the affected joint. Consequently, the following sections will describe
the different uses of exoskeletons for rehabilitation treatment of patients with motor
impairments and their different human-machine interaction approaches. Gathered
information is classified according to the different characteristics of the technological
developments and experimental methods and techniques, i.e. by mechanical and actuation
design, control strategy, sensing, therapeutic task and protocol, intervention, performance
evaluation and even the population selection.

3.1. Exoskeletons for upper limbs

According to [4], early publications related to robotic rehabilitation were based on end-
effector robots, which hold the patient’s hand or forearm to apply forces in order to describe
desired motions. However, the joints of such robots do not match with the those of human,
which implies many limitations, including not being capable of control the torque at specific
limb joints and a reduced range of motion.
On the contrary, exoskeleton’s joint axes match with human joint axes, and therefore can
be attached at multiple points and apply controlled torques to each joint separately.

Target population, intervention, and performance evaluation.

Most of the researchers have focused on Stroke, since it is the most common cause
among motion disorders for upper limbs [1], such as in the works developed in [14]–[16],
but some other studies have designed devices to treat other pathologies such as
arthrogryposis, multiple sclerosis, cerebral palsy, spinal muscular atrophy and muscular
dystrophy, among others [17]–[19]. Fig. 1 shows some of these studies, that mostly focus
on developing devices for right hemiplegia: the L-Exos [20], the WREX [17], [19].
It is also interesting to point the work developed in [21] (See Fig. 2 (a)), where the device
was developed to treat tremor suppression among patients with essential tremors, multiple
sclerosis, traumatic and mixed tremors. What is interesting is the use of the sensors
(gyroscopes) to calculate the power in the frequency band of 2-8 Hz to assess the tremor
reduction.

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 (a) (b) (c) (d)
Figure 1. (a) L-Exos (Light Exoskeleton), (b) and (c) WREX
(Wilmington robotic Exoskeleton), (d) Hand exoskeleton
In fact, many researchers have used several techniques and standardized instruments to
assess the efficacy of the exoskeletons, mainly on the recovery of the motor function, by
means of accuracy of trajectory following [18], by using tests such as Fugl-Meyer or
Ashworth scale (muscle spasticity) [22], but overall by measuring the activity levels of
muscles, i.e. less EMG (electromyography) activation, such as in [23], [24]. Some others
have used proportional derivative (PD) control method to evaluate the exoskeleton
performance from a mechanical point of view, such as [25], [26], and in fact, it is used as a
common control strategy [18], along with impedance and force feedback [15], [21], [23],
obstacle avoidance controllers (OAC) [24] and neuro-fuzzy modifiers, used to tune the
muscle models.

(a) (b) (c)

Fig. 2. (a) Exoskeleton for tremor assessment and suppression, (b) ARMin and
(c) Cable-driven Robotic exoskeleton.

Upper-limb exoskeleton’s mechanical design.

A detailed analysis of the mechanisms involved in actuation systems for joint
rehabilitation and mobility is needed, mainly by studying the different types of joint motion
in the human body. In this study it was observed that in upper limbs it is important to
develop mechanisms that mimic or follow the paths of both arm and hand.
Regarding to the DOF, researchers have been developed exoskeletons according to the
motions that are intended to be treated. For instance, the NEUROExos is an exoskeleton
only for flexion/extension of the elbow and it focuses in the effectiveness in aligning the
robot with the user’s elbow axis [15]. However, most of the works have tried to include at
least 7 DOF by only excluding the sternoclavicular joint and the hand, such as the SRE and
the SUEFUL-7 robots [16], [23].
According to Lo and Xie, the majority of existing exoskeletons work with
electromagnetic motors [4], mainly DC brushless motors or servomotors. However, there
is an increasing interest in the use of pneumatic muscle actuators (PMA), i.e. they also set
tension via contractions, like in the RUPERT IV and the works developed in [27]–[29]. In
order to compensate the weight of such actuators, researchers have mounted the entire
device over wheelchairs, such as in the ARMin (see Fig 2 (b)), or by placing them far from
the joints and using pulleys and cables for power transmission [30] (see Fig 2 (c)). Another

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 approach is the inclusion of an elastic element in series to the actuator to reduce the high
impedance of the electric motors, which is known as a Series Elastic Actuator (SEA), such
as the MARIONET [31], UHD[32], the MACCEPA design to provide compliant actuation
[33], [34] and the series rotational hydroelastic actuator (rHEA) proposed by [35].
Finally, the employed sensor used to be for measuring rotational position and velocity
(potentiometers and encoders), acceleration (Inertial Measurement Units - IMU),
force/torque (gauges and load cells), current, and even volition to move by means of EMG,
such as the Myomo e100[36], the W-EXOS [37], the PolyJbot[38], and the above-
mentioned SUEFUL-7.

3.2. Exoskeletons for rehabilitation and mobility of fingers.

Over time it has become necessary to create devices for stroke rehabilitation in the carpal,
metacarpal and phalanges as shown in the following works. In the first place, in [39] an
exoskeleton was implemented for the index finger with independent drive for each of the
joints used in the flexion and extension of the same. This system was developed with the
objective of evaluating the optimization strategies in the rehabilitation of patients with
cerebrovascular damage.
In [40] it was investigated the control algorithm of an exoskeleton for rehabilitation of
the index finger that is formed by the actuator module and the module of the exoskeleton.
The exoskeleton is powered by DC motors for movement of the proximal interphalangeal
joint (PIP) and subsequent rehabilitation thereof. In this way, in [41] an exoskeleton has
four degrees of freedom for hand rehabilitation through movement transmission cable.
Continuing with [42], based on the design of a mechanism for moving bars
interphalangeal phalangeal dorsal proximal and metacarpophalangeal. Aditionally,
analyzed the kinematics and workspace of a skeleton on the thumb and forefinger. In second
place, [43] proposed a differential mechanism, seamless for each of the finger joints in order
to generate force in the fingertip to complete the general daily tasks.
Likewise, [44] developed the design an exoskeleton of three fingers, where the
movements of the phalanges are monitored by a pressure sensor array. This device was
designed to allow the astronaut accuracy in the grip with the thumb and index finger, plus
the pressure in the subject. In [45] a coupled device is implemented to a linear actuator for
moving the distal phalanges finger. On the other hand, a exoskeleton hand was designed by
[46] for rehabilitation and recovery applications in motion in the joints of the fingers.
Similarly, [47]based on the rehabilitation of the index finger and thumb, focused on the
gripping and holding objects with these two fingers. This mechanism consists of rods,
which allow the movement of each joint in flexion and extension.
The research of [48] designed a thumb and forefinger to hold the ordinary and fine; each
of the phalanges that form is surrounded by aluminum cylinder connected to wires that
simulate tendons joint. Likewise, in [49] a robotic device was implemented specifically for
people who have suffered strokes. The device detects the motion intention by EMG.
Heo et al. conducted a literature review of the devices designed for the rehabilitation and
subsequent movement of the joints [50]. Similarly, in [51] a design for the rehabilitation of
the hand is made; this implementation focused on maximum security, comfort, reliability
and interaction with the patient. Therefore, one of the important features in this
development is adaptability in patients with different body shape. Finally, [52] shows how
the implementation could be based on data acquisition by electromyography and force
feedback on the device

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 3.3. Exoskeletons for lower limbs.
In the area of design and construction of devices in the field of rehabilitation are the
following technological advances. In [53] it was designed and controlled a system that
integrates the intellect of the human control to manipulate the power-assisted portable
device, and also the viability of the system is discussed. On the other hand, in [54]
developed a lower-limbs exoskeleton (BLEEX) for transporting heavy loads on uneven
terrain. Similarly, [55] describes the design and control of a pneumatic muscle actuator,
designed for the rehabilitation of patients with rheumatoid arthritis, chronic inflammation,
osteoarthritis, progressive disorders in joints and bursitis. This device named (HME),
connecting from foot to hip and uses an actuator for each leg, and a PLC for control system.
In [56] a design is shown to maintain a spring that retains the adequate tension. Otherwise,
in [57] a device in order to increase the capacity in the human is implemented. This device
has an architecture that allows an arrangement of springs in the hip, knee and ankle.
Likewise, [58] design a machine for patients with gait disabilities. The study shows the
advantages of the project such as reducing dependence on the clinical and quantitative
assessment of the level of recovery. In [59] the evolution of quantitative changes of kinetic
and kinematic gait foot is provided, when the subject wears an exoskeleton; plus, the long-
term effects of a device gait rehabilitation in stroke patients with hemiparesis were studied.
Moreover in [60] design an exoskeleton named LOPES, this device consists of three
rotational joints, two at the hip (adduction and flexion) and one knee (flexion), as shown in
Fig. 3 (a).
In [61] rehabilitation exoskeleton gear driven by artificial muscles tire develops. This
device consists of four parallel rods in a unilateral exoskeleton and adjustable support arm
as shown in Fig. 3 (b). Similarly, in [62] a robotic suit with ten DOF to increase strength
and gait training in individuals with cerebral palsy was designed, as shown in Fig. 3 (c).
Continuing [63], is a controlled device independently hip and knee for therapeutic
analysis of the rehabilitation of patients, it is also adjustable in height and has a software
algorithm especially designed to interpret the signs of the inclination of the torso and as a
result plays the bipedal gait as shown in Fig. 3 (d).
On the other hand, in [64] harmonic drive actuator and pneumatic artificial muscles
(PAMS) for movements of extension and flexion of the hip joints and the knee was used.
Following with [65], was implemented a portable robotic device for the rehabilitation of
the locomotion of pediatric patients with neurological diseases such as cerebral palsy. The
principle of operation is based on said series elastic actuator. Likewise, in [66] was
developed an external structure that provides protection and support for the study of the
biomechanics of the human lower limb.

(a) (b) (c) (d)

Figure 3. (a) LOPES Exoskeleton, (b) Exoskeleton for gait rehabilitation,
(c) IHMC and (d) ReWalk.

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 Exoskeletons for gait rehabilitation
Among rehabilitation systems running the following are mentioned: in [67] different
gear rehabilitation devices are analyzed as LOKOMAT, Roboknee, ExoHiker, XOS, HAL-
5 and the impact they have had in the rehabilitation of patients with cerebral palsy.
Similarly, in [68] device gait training for patients with cerebrovascular damage was
designed: for rehabilitation of joint forces are applied in order to achieve normal driving
patterns.
Similarly, the objective of [69] was to study the effect of assisted therapy an exoskeleton
adapted to a treadmill. To this end, they submitted twenty therapies to patients with bilateral
spastic cerebral palsy with an intensity of 12 sessions. Thus, in [70] computer-aided training
is studied with the system LOKOMAT. In [71] the main objective of the research was the
restoration of independent walking. To achieve the above subjects are trained in normal gait
patterns and learning processes of the central nervous system are stimulated; the machine
used is the GEO. Besides, in [72] a literature review of the training devices and
rehabilitation march was held. Alike, in [73] a study of existing robotic systems for
rehabilitation of the lower limbs occurs, conducting a review to all current robotic systems
to date for the rehabilitation of the lower extremities, as well as major clinical tests with
them this order show a clear starting point in the field of rehabilitation. In [74] features like
the mobile platform, interface manipulation, harnesses and restraint, and its overall
performance are analyzed. Similarly, in [75] the device HMI (Human Machine Interface)
provides users with lesions of the spinal cord reliable, secure, and intuitive way to control
e-LEGS.
On the other hand, in [76] the issue of rehabilitation and gait training in the development
and optimization of the same with an external device helps addressed. For this restoration,
the system was used ALEX y LOKOMAT, which they are related to motion paths on the
ankle, knee and hip. Just as in [77] a neuro-fuzzy control in order to decode the human body
motion is included.
In analogy to what above described, in [78] the feasibility of rehabilitation training with
a new portable robot is investigated. Finally, the results of the research include significant
improvements in walking speed, number of steps, and others. In [79] a new device is
developed as a suit with a mobile support for upper and lower limbs, which allow
facilitating the activities of daily life. Moreover, in [80] a robot rehabilitation environment
that mimic real life situations allowing simultaneous exercise of the upper and lower
extremities was created. This paper describes the development and design of the new robot
arm described, their integration into the LOKOMAT. In [81] presents a design for the lower
limb according to the technology of supporting and holding body weight.
Likewise, in [82] there is a sensor arrangement for an exoskeleton based on the difference
between the coordinated movement of the human leg and human machine introduced.
Similarly, In [83], the phase-two prototype named ALEX II was designed under the
following two configurations: 1) blocking the anterior / posterior translation in the
exoskeleton, 2) maintain the anterior / posterior degree of freedom unlocked. For this, the
healthy subjects walked on a treadmill with an average acceleration and were trained to
walk up a new template. In [84] a robotic platform for post-surgical rehabilitation of people
with cerebral palsy (CP) is presented. The CP-Walker platform combines an intelligent
walker and an exoskeleton with advanced interfaces (BCI EMG) that allows human-robot
interaction. In this paper both the conceptual design described as the development of CP-
Walker platform.

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 4. Conclusion
The present paper presented an overall description of relevant articles in the field of
design and construction of external devices for rehabilitation. It can be concluded that
different strategies can be used to contribute on the rehabilitation of motor disabilities with
upper-limb motor disorders, mainly for stroke survivors and elderly population with weak
muscle tone. Most of the studies have tried to mimic all the upper-limb joints, by only
excluding one degree of freedom in the wrist and the shoulder elevation to simplify the
designs and experimental settings. Sensors are placed to identify joint’s position and torque,
but also to predict motion intention. Active exoskeletons deal with the weight of electrical
of pneumatic actuators and therefore tend to use cables and pulley for power transmission,
as well as to use elastic components and impedance feedback controllers to promote
compliant actuation.
Regarding the lower limb exoskeletons, the literature suggests that the work of greater
impact are the Robotknee, POGO and PAM Manipulator, The Gait Trainer, Haptic Walker,
Auto-Ambulator, Lokomat, LOPES (Lower Extremity Powered Exoskeleton), ARTHUR,
BLEEX (Berkely Lower Exoskeleton) and GEO. These elements are essential in correcting
gait disorders in joints such as hip, knee and ankle because it creates an alternative
functional training, according to the guidelines established by physiotherapists and
recovery of joint movement. Other advantages of these external devices are little
dependence of the movement with the therapist and the evolutionary study of the recovery
of existing diseases.

Acknowledgments
This paper as well as the High Impact Project ING-IMP-2657 - “Platform for evaluation
of therapeutic adherence and its influence on the efficiency of stabilometry therapies”. thus
we are grateful with the Vicerrectoria de Investigación of the Universidad Militar Nueva
Granada for their support, and with every single researcher that make this project, this robot
a reality. Authors want to thank Karin S. Muñoz for their valuable support on this work

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