Exoskeletons in Neurological Diseases–Current and Potential Future Applications

Abstract

An exoskeleton is a distinctive kind of robot to be worn as an overall, effectively supporting or, in some cases sub-stituting for, the user's own movements. The development of exoskeletons can lead to important changes in the rehabilitation of disabled people by introducing an alternative to wheelchairs. Exoskeletons can be an efficient tool in gait re-education and in the restoration of upper limb functions, and they can support therapists and caregivers in tasks that require major physical effort. The functionality of exoskeleton can easily be extended by a "disabled person integrated IT environment", described by authors. Exoskeletons can also be easily adapted to the needs of severely ill or aged people (Adv Clin Exp Med 2011, 20, 2, 227–233).

Full text

E M, D M
Exoskeletons in Neurological Diseases
– Current and Potential Future Applications
Egzoszkielety w terapii schorzeń neurologicznych
– zastosowania obecne i przyszłe
1 Rehabilitation Clinic, Military Clinical Hospital No. 10 and Polyclinic, Bydgoszcz, Poland
2 Division of Applied Informatics, Department of Physics, Astronomy and Applied Informatics,
Nicolaus Copernicus University in Toruń, Poland
Abstract
An exoskeleton is a distinctive kind of robot to be worn as an overall, effectively supporting or, in some cases sub-
stituting for, the user’s own movements. The development of exoskeletons can lead to important changes in the
rehabilitation of disabled people by introducing an alternative to wheelchairs. Exoskeletons can be an efficient tool
in gait re-education and in the restoration of upper limb functions, and they can support therapists and caregivers
in tasks that require major physical effort. The functionality of exoskeleton can easily be extended by a “disabled
person integrated IT environment”, described by authors. Exoskeletons can also be easily adapted to the needs of
severely ill or aged people (Adv Clin Exp Med 2011, 20, 2, 227–233).
Key words: neurological diseases, rehabilitation, robotics, exoskeleton, hospital care, home care.
Streszczenie
Egzoszkielet to szczególny rodzaj robota zakładanego na użytkownika w formie kombinezonu skutecznie wspo-
magającego lub, w wybranych przypadkach, zastępującego jego ruch. Rozwój egzoszkieletów może doprowadzić
do zmian w rehabilitacji osób niepełnosprawnych dzięki wprowadzeniu alternatywy dla wózków dla osób niepeł-
nosprawnych, wykorzystanie egzoszkieletów jako skutecznych narzędzi do reedukacji chodu i czynności kończyn
górnych oraz jako wsparcie terapeutów i opiekunów osób niepełnosprawnych, ciężko chorych i w podeszłym wieku
przy wykonywaniu czynności związanych ze znacznym wysiłkiem fizycznym. Funkcjonalność egzoszkieletu może
zostać zwiększona dzięki włączeniu go w przedstawione przez autorów „zintegrowane środowisko teleinformatycz-
ne osoby niepełnosprawnej”. Prezentowane rozwiązania mogą w łatwy sposób być przystosowane do potrzeb osób
ciężko chorych lub w podeszłym wieku (Adv Clin Exp Med 2011, 20, 2, 227–233).
Słowa kluczowe: choroby neurologiczne, rehabilitacja, robotyka, egzoszkielet, opieka szpitalna, opieka domowa.
Adv Clin Exp Med 2011, 20, 2, 227–233
ISSN 1230-025X
REVIEWS
© Copyright by Wroclaw Medical University
An exoskeleton is a distinctive kind of ro-
bot to be worn as an overall or frame, effectively
supporting, or in some cases substituting for, the
user’s own movements [1–4]. The aim of this ar-
ticle is to discuss the possible use of exoskeletons
in the treatment of neurological diseases, including
neurorehabilitation. The authors have reviewed
publications in the PubMed database (Figure 1);
the keyword “exoskeleton” does not occur in the
MeSH database.
Exoskeletons are still at the early stages of
their development. They need detailed technical
and clinical research not only in the area of safety,
but also in terms of their influence on the human
body, biomechanics and mind. It seems that in the
future exoskeletons may become a form of therapy
in neurological diseases and neurorehabiltiation.
Exoskeletons can be divided into two catego-
ries: those for all four extremities (arms/legs) and
those for the lower extremities only.
Exoskeletons are controlled by the user’s
movements and do not need any external control
terminal (with the exception of a service terminal).
The main parts are: the frame; the power system,
including engines, actuators and batteries; and the
control system with sensors.

E. M, D. M
228
frequency of specified keywords
częstotliwość występowania
poszczególnych słów kluczowych
key words
słowa kluczowe
number of
articles
liczba
artykułów
exoskeleton
(not useful
in the case)
exoskeleton +
rehabilitation
exoskeleton +
disabled people
573
49
2
1890:
N. Jagn (USA)
patents an
"apparatus for
facilitating
walking,
running and
jumping"
19th century 20th century 21st century
1959:
R. Heinlein
(USA) writes
the novel
Starship
Troopers, which
inspires
exoskeleton
designers
1966:
GE Research
(USA) produces
the first
exoskeleton
1991:
J. Dick of
Applied Motion
Inc. (USA)
patents the
SpringWalker
Body Amplifier
2001–2008:
The Defense
Advanced
Research
Projects Agency
(USA) develops
exoskeletons
including XOS,
HULC and
BLEEX
2008–2015:
The Defense
Advanced
Research
Projects Agency
(USA) develops
advanced
version of XOS
exoskeleton
since 2000:
exoskeletons
including
HAL5, Re
Walk, WPAS
and RoboKnee
researched in
USA, Japan,
Great Britain,
Germany Italy
and elsewhere
Fig. 1. Results of investigation of the PubMed
database (U.S. National Library of Medicine) [5]
Ryc. 1. Wyniki przeszukiwania bazy danych
PubMed (U.S. National Library of Medicine) [5]
Fig. 2. Milestones in the history of exoskeletons
Ryc. 2. Kamienie milowe w historii egzoszkieletów
Exoskeletons
medical military multipurpose
HAL5, Y. Sankai,
University of Tsukuba
and Cybercyne Inc.,
Japan
ReWalk B1 and B2, Argo
Medical Technologies,
Israel
WPAS (Wearable
Power Assist Suit)
K. Yamamoto,
Kanagawa Institute of
Technology, Japan
RoboKnee, B.T.
Krupp, C.J.
Morse,Yobotics
Corporation, USA
BLEEX 2, H. Kazerooni,
University of California,
USA
ExoCarrier, Berkeley
Bionics, USA
ExoClimber, Berkeley
Bionics, USA
XOS Exoskeleton,
Sarcos Research
Corporation and
Raytheon, USA
HULC (Human
Universal Load
Carrier), Lockheed
Martin and Berkeley
Bionics, USA
Fig. 3. The main current exoskeletons
Ryc. 3. Najważniejsze współczesne egzoszkielety

Exoskeletons in Neurological Diseases 229
Generally, the main features that are impor-
tant for exoskeleton users are: the means and level
of support; the ways the device is controlled and
how the user conveys intentions: EEG, electromy-
ography (EMG), angle sensors, pressure sensors,
etc.; the weight; limitations due to the user’s height
and length of limbs; the time and effort needed
for fitting and pre-setting the exoskeleton before
its first use; convenience and comfort in all-day
use; the time needed to recharge batteries; in some
cases, the possibility of folding and transporting
ready-to-use (programmed) exoskeleton; the exo-
skeleton’s self-diagnostic capabilities; compatibility
with local intelligent systems (smart home, i-wear,
Ambient Intelligence, etc.) at home, at work, in
the hospital, etc.; trends in the development of
exoskeletons, including their integration into dis-
abled people’s wider environments, including the
need for sufficient levels of home care and therapy,
telerehabilitation and distant supervision (distant
measurement of parameters, alerts, etc.).
Further technical developments are needed to
solve current limitations and problems with exo-
skeletons: longer-lasting power batteries; lighter
and stronger materials for the frame; more powerful
actuators; more sophisticated control systems, such
as EEG instead of EMG, advanced neuroprostheses
and Brain-Computer Interfaces (BCIs), more effi-
cient processes of fitting and customizing.
Support for User Intent
in Exoskeletons
Information for the exoskeleton control sys-
tem can usually be provided by several sets of sen-
sors: EMG sensors or sensors of other bioelectric
activity attached to skin; angle sensors, pressure
sensors, gyroscopes, accelerometers, etc., attached
to the frame of the exoskeleton: in the future, EEG
sensors, pulse rate sensors, etc., attached to the
skin or implanted. Additionally, the power system
provides information about the working load in
each part of the exoskeleton and about the power
reserve. Generally, the procedure of assisting the
user with an intended movement is as follows:
1) analysis of the current situation: posture, limb
positions, etc., based on signals collected from
EMG or other sensors (muscle contraction, etc.);
2) when the user attempts to move: the exoskel-
eton control system analyzes the sensor signals and
determines the user’s intended movement; 3) the
control system selects a pre-programmed move-
ment pattern, adjusts it to the user’s current po-
sition and supports the movement with actuators
using the appropriate force; 4) after completing the
movement, the control system analyzes the new
situation – posture, limb positions, etc. – assessing
and preparing for the user’s next possible move-
ments [7–9].
This algorithm also includes balance control
(necessary for fall protection) [10] and co-ordina-
tion of several movements at the same time. An
exoskeleton can have two or more control systems
working together, e.g. the HAL5 exoskeleton with
Fig. 4. Examples of medical exoskel-
etons: a) HAL5 – version for four
extremities [1], b) ReWalk
Ryc. 4. Przykłady egzoszkieletów
medycznych: a) HAL5 – wersja
czterokończynowa [1], b) ReWalk
BA

E. M, D. M
230
two control systems: Cybernic Voluntary Con-
trol, based on bio-electric signals observed on the
surface of the skin, and the Robotic Autonomous
Control System, based on a database of elementary
movements, allowing for exoskeleton movements
despite poor bio-electric signals from the user.
For patients with hemiparesis, it is important
to provide more support for the affected side. For
safety reasons it is necessary for the exoskeleton to
work properly even in emergency situations, e.g.
when the sensors unexpected malfunction. Also,
an exoskeleton being worn by user must not col-
lapse even if the battery is low. An easy-to-operate
emergency switch-off systems for disable people
(e.g. a puff/sip switch) is also necessary.
Medical Uses
of Exoskeletons
Generally an exoskeleton is a technical tool
that expands and improves selected abilities of the
user. From a medical point of view, it can serve as a
multi-purpose medical device: as an alternative to
wheelchairs (both powered and manual), provid-
ing mobility and increasing patients’ possibilities,
especially in climbing stairs. Using an exoskeleton
is closer to natural human mobility than using a
wheelchair; as an efficient supplementary tool in
gait re-education and as an option in restoring
upper-limb functions. Exoskeletons are perceived
as probably more effective than the traditional as-
sistance and support of therapists and rehabilita-
tive devices (e.g. rehabilitative robots) [13–15]; to
support therapists and caregivers in tasks requir-
ing major physical effort, e.g. patient transfer; as a
tool for gaining a better understanding of human
body posture and movement.
Because of this wide range of possibilities it
is important to develop medical exoskeletons, de-
signed for use in the therapy of patients with CNS
diseases, stroke or spinal cord injury (SCI). In this
kind of therapy exoskeletons can provide: all-day
supported mobility, with a full range of motions
and proper movement patterns; the possibility of
training in (or re-learning of) all functional activi-
ties: lying, sitting, standing, walking, transfer, stair
climbing, ascending/descending slopes and activi-
INTEGRATED
IT
ENVIRONMENT
OF DISABLED
PEOPLE
Exoskeletons and
walking assistive
devices as an
alternatives
to wheelchairs
Intelligent
multifunctional
wheelchair with
GPS, mobile phone,
robot
Smarthomes
with intelligent
equipment,
i-wear, bedside
robots, nursing
robots
Nanomedical
systems (artificial
agents) and other
future
solutions
Neuroprostheses,
Brain-Computer
Interfaces
E-health,
telemedicine
(incl.
telerehabilitation)
e-learningCar with
assistive devices
Computers for
disabled people with
assistive devices
INTEGRATED ENVIRONMENT
OF DISABLED PEOPLE
BOTH INDOOR AND OUTDOOR
OR OUTDOOR ONLY
INDOOR
Fig. 5. Exoskeletons within
the concept of disabled
people’s integrated IT
environment [6]
Ryc. 5. Miejsce egzo-
szkieletu w ramach
koncepcji zintegrowane-
go środowiska osoby
niepełnosprawnej [6]

Exoskeletons in Neurological Diseases 231
ties of daily living (ADLs) in a way similar to nor-
mal life (some exoskeletons even permit the users
to drive cars); efficient support for weak patients,
improving their muscle strength, bone density,
cardiovascular system and endurance, to prepare
them for normal functioning; the possibility of
nearly-natural all-day functioning, with posture
and movements that are better for the digestive,
respiratory and urinary systems; a reduction in the
energy expenditure required for exercises [16–18].
Because exoskeletons are multi-purpose ro-
bots their wide implementation could decrease
the number of rehabilitation tools needed, and
the total cost of rehablitation. Generally, the use
of exoskeletons can: increase the possibilities and
effectiveness of rehabilitation, especially neurore-
habilitation, through intensive all-day functional
therapy during normal life activities; increase the
accessibility of rehabilitation, including home re-
habilitation and home care; increase the user’s
safety (fall protection); save money and time, de-
creasing the average hospital stay and the number
of therapists needed per patient (especially in gait
re-education); stimulate developments in other
branches, e.g. geriatric therapy and care.
These developments require additional clinical
research following the Evidence-Based Medicine
paradigm, to provide standards and guidelines for
prescribing, selecting and fitting the exoskeleton
and conducting the therapy; for effectivity assess-
ment, safety and troubleshooting; for the training
of medical staff, especially physiotherapists; and for
the training of users and carers. Clinical research on
the medical exoskeleton HAL5 (Hybrid Assistive
Limb 5) is being conducted at Danderyds Hospital
in Sweden and Odense Universitetshospital in Den-
mark; and on the exoskeleton ReWalk at the Chaim
Sheba Medical Center Neurological Rehabilitation
Department (Israel), and at the MassRehab Massa-
chusetts Rehabilitation Commission (USA).
The Prospects
for Clinical Use
The clinical use of exoskeletons requires the
co-operation of a whole multidisciplinary team,
including biomedical engineers. It calls for careful
preparation, and could consist of the stages de-
scribed below.
1) Patient preparation:
– explaining the procedures to the patient;
– assessment of the patient’s health status (in-
cluding secondary health problems, indications
and contraindications);
– functional diagnosis: what the patient can
do, hidden potentials, deficits and limitations;
– anthropometric measurements;
– clinical gait analysis;
– other movement analysis: upper limbs and
spine evaluation;
– assessment of the patient’s way of life and
ADLs;
– discussion of the preferences, goals and mo-
tivation of the patient and caregivers (e.g. in the
area of home rehabilitation);
– assessment of the patient’s possibilities for
controlling the exoskeleton (cognitive and func-
tional deficits, limitations and weaknesses);
– choice of exoskeleton type and features (di-
mensions, ranges of adjustment, modes of support
and control, etc).
It is important to emphasize the fact that an
exoskelton works with the user, so the user must
be able to control the exoskeleton properly. Using
the exoskeleton should help the patient to achieve
therapeutic goals, functional independence and an
improved quality of life more efficiently than tra-
ditional therapy.
2) Exoskeleton fitting and set-up:
– matching the exoskeleton features to the pa-
tient’s current health status and anthropometric
measurements;
– implementing patterns of the patient’s pos-
ture (lying, sitting, standing, etc.), transfer (sitting
to standing, etc.), gait and other activities such as
stair climbing, ascending/descending a slope and
ADLs;
– adjusting the level of exoskeletal support and
the exoskeleton control modes;
– trials with the patient and fine-tuning adjust-
ments.
Exoskeletons need to be comfortable, conve-
nient and functional for all-day use, and allow the
user to move in the most natural way possible.
3) Clinical trials with the patient:
– training with the patient and caregivers, in-
cluding emergency situations;
– assessment of the effectiveness of the thera-
py, including the influence of other rehabilitation
methods used at the same time;
– assessment of functioning, comfort and
convenience, and of the patient’s adaptation to
human-robot interaction;
– analysis and implementation of conclusions
in both the exoskeleton technology and the way
the therapy is conducted.
At present, stages 1–3 can last up to several
months. There is a clear need to reduce this time
span by introducing standards and clinical guide-
lines.
4) Normal clinical use:
– therapy with the patient (including the fam-
ily and caregivers if necessary);

E. M, D. M
232
– assessment of the goals and results of the
therapy, including the patient’s preferences;
– implementation of the conclusions;
– if necessary, establishing a program of nor-
mal home use.
The use of an exoskeleton during acute rehabil-
itation and hospitalization is a only a supplement
to other forms of therapy, such as physiotherapy,
kinesitherapy and pharmacotherapy, However, if
a patient needs only exoskeleton therapy (e.g. in
gait re-education), this can be provided on an out-
patient basis or at home. Additional studies are
needed to establish standards and guidelines for
the safe and effective use of exoskeletons in home
rehabilitation programs under the regular over-
sight of a therapist.
5) Normal home use and rehabilitation (op-
tional):
– normal all-day home use of the exoskeleton,
including therapy (from simple exercises to telere-
habilitation),
– ongoing assessment of the patient’s health
status and functional abilities, including secondary
changes such as pressure ulcers;
– continued assessment of the goals and re-
sults of the therapy;
– ongoing assessment of the technical condi-
tion of the exoskeleton;
– analysis and implementation of conclusions.
It is important to emphasize that in a sig-
nificant percentage of patients it may be possible
to abandon the exoskeleton after therapy and to
live normally without it, and the therapy should
be conducted in a manner that takes this into ac-
count.
All of the procedures proposed above call for
more clinical research and detailed guidelines.
Conclusions
Exoskeletons can significantly change the
model of therapy in neurological diseases and the
lives of disabled people, improving their quality of
life and their chances for independence, education,
work and entertainment. The further development
of control systems, especially neuroprostheses and
brain-computer interfaces, can significantly im-
prove access to this form of therapy for people
with severe deficits. Broadening the medical uses
of exoskeletons can stimulate development of oth-
er branches such as geriatric therapy and care.
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Exoskeletons in Neurological Diseases 233
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Address for correspondence:
Emilia Mikołajewska
Rehabilitation Clinic
Military Clinical Hospital No. 10 and Polyclinic
Powstańców Warszawy 5
85-681 Bydgoszcz, Poland
E-mail: e.mikolajewska@wp.pl
Conflict of interest: None declared
Received: 3.12.2010
Revised: 11.02.2011
Accepted: 24.03.2011