So ask your competent? doctor which soft robotics already out there will help you recover. Don't take; 'I don't know' for an answer. If your doctor doesn't know about all of these; you don't have a functioning stroke doctor! In my opinion a stroke doctor should be up-to-date on ALL stroke research! Since these interventions are not meeting stroke survivor needs your doctor should be initiating research to meet those needs.
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The-state-of-the-art of soft robotics to assist mobility: a review of physiotherapist and patient identified limitations of current lower-limb exoskeletons and the potential soft-robotic solutions
Journal of NeuroEngineering and Rehabilitation volume 20, Article number: 18 (2023)
Abstract
Background
Soft, wearable, powered exoskeletons are novel devices that may assist rehabilitation, allowing users to walk further or carry out activities of daily living. However, soft robotic exoskeletons, and the more commonly used rigid exoskeletons, are not widely adopted clinically. The available evidence highlights a disconnect between the needs of exoskeleton users and the engineers designing devices. This review aimed to explore the literature on physiotherapist and patient perspectives of the longer-standing, and therefore greater evidenced, rigid exoskeleton limitations. It then offered potential solutions to these limitations, including soft robotics, from an engineering standpoint.
Methods
A state-of-the-art review was carried out which included both qualitative and quantitative research papers regarding patient and/or physiotherapist perspectives of rigid exoskeletons. Papers were themed and themes formed the review’s framework.
Results
Six main themes regarding the limitations of soft exoskeletons were important to physiotherapists and patients: safety; a one-size-fits approach; ease of device use; weight and placement of device; cost of device; and, specific to patients only, appearance of the device. Potential soft-robotics solutions to address these limitations were offered, including compliant actuators, sensors, suit attachments fitting to user’s body, and the use of control algorithms.
Conclusions
It is evident that current exoskeletons are not meeting the needs of their users. Solutions to the limitations offered may inform device development. However, the solutions are not infallible and thus further research and development is required.
Introduction
In the UK, 6.8 million people live with mobility-related disabilities; the leading causes of which are musculoskeletal conditions and stroke [1, 2]. Persons with stroke are living longer due to reductions in risk factors and improvements of treatments [2]. The population overall is also aging; the number of people living over 85 is expected to increase from 1.8 million in 2018 to 3 million by 2043 [3]. Musculoskeletal impairments are associated with older age, therefore both those with musculoskeletal impairments and stroke survivors are living longer with disabilities that require assistance [2, 4].
Impaired mobility can have widespread effects on an individual’s quality of life as participation challenges impact their work, social life and activities of daily living (ADLs) [5]. Mobility impairments are also a risk factor for falls which reduce an individual’s confidence and self-belief in their own mobility, and can lead to activity avoidance, social isolation and depression, which in turn increases frailty and the ‘fear of falling’ cycle [6,7,8]. Thus, the paramount goal for physiotherapy rehabilitation is to ensure the continued mobility of individuals, with evidence demonstrating that, for neurological patients, repetitive movements are crucial to re-learn motor functions [9]. This is not without its challenges; in the UK, persons with stroke typically receive only 35 minutes of inpatient physiotherapy per day, despite the guidance of 45 minutes minimum [10, 11]. Increasing rehabilitation time may not be achievable as traditional rehabilitation frequently requires body weight support of the patient, which can be physically demanding for the physiotherapist who may require assistance from others [12, 13]. Consequently, therapist fatigue and staffing capacity limits what a patient is able to achieve in a session [13]. Assistive devices such as walkers are commonly provided to patients with mobility impairments [14]. These devices fall under the umbrella of ’assistive technology’, which describes products or systems that assist individuals with disabilities, restricted mobility or other impairments to perform functions that might otherwise be impossible or challenging [15]. Although assistive devices can improve rehabilitation of muscle and neural processing, they have limitations that prevent individuals from carrying out their ADLs as normal [14]. Reported challenges include opening of doors or getting on to public transport when using four-wheeled walkers, and issues carrying items, food and drink when using a walking stick [14, 16, 17].
Development in wearable powered exoskeletons offers a potential solution to traditional rehabilitation challenges [18, 19]. An exoskeleton, also known as a wearable robot, is a mechanical system worn by humans to augment, complement or substitute the function of the wearer’s limbs [20]. Early developed exoskeletons were stationary devices used to train patients on a treadmill with body-weight support, reducing loads on lower limbs for rehabilitation, such as DGO [21], LOPES [22] and ALEX [23]. Later, commercially available, portable assistive exoskeletons were developed, including Ekso, Rewalk [24], Indego and Exo H2 with an increasing number in development [12, 25]. Although not identical, their principles and designs are similar, consisting of an external actuator(s) fitted in parallel with weak or paralysed lower limbs to assist with mobilising and activities of daily living [26].
Many of these existing rigid exoskeletons were initially developed to provide maximal assistance to those with complete paralysis resulting from spinal cord injury. Interest has increased in the exoskeletons that can provide sensory-guided motorised lower limb assistance for person’s with stroke [27, 28]. These devices provide partial assistance during mobility tasks, allowing persons with stroke to actively participate through practising postural control and locomotion patterns [12]. A systematic review with a meta-analysis demonstrated that rigid exoskeletons are safe, with no reported adverse events, with falls only reported in a study using an early prototype [26, 29]. Further, rigid exoskeletons have widespread benefits including increased walking time, number of steps and improved strength and postural control in stroke survivors [30]. Studies have only recently explored patients and physiotherapists’ perspectives of the use of exoskeletons [18, 25, 31]. A key advantage of existing rigid exoskeletons was their ability to reduce the physical strain on therapists, therefore fewer members of staff would be needed to assist a patient, increasing the service’s capacity [18, 31]. The ways in which exoskeletons may have psychosocial benefit to individuals was also highlighted, including the potential improvement to a patient’s confidence and feeling of independence [18, 31].
Despite these proposed advantages, rigid exoskeletons have not been widely adopted clinically [32]. Although a systematic literature review on user perspective of rigid exoskeletons has been undertaken previously by Hill et al. [33], the review only included three papers which had limited reporting of qualitative data and their methods were predominantly quantitative components [29, 34, 35]. The review was inconclusive on user perspectives of rigid exoskeletons due to the minimal amount of evidence that has been undertaken; nevertheless, they concluded that users are able to offer their opinions, which may facilitate the design process. Since the publication of the Hill et al. [33] review, there has been further research into patient and physiotherapists’ perspectives; papers highlighted a range of rigid exoskeleton limitations, and they also recognised their novelty and potential [18, 25, 31]. Common perceived limitations or concerns regarding rigid exoskeletons across studies included: safety issues such as joint misalignment; creation of only one device to fit all patients; difficulty of use, including donning and doffing; weight and cost; and device appearance [18, 25, 31, 36]. User perspectives for traditional rigid exoskeletons demonstrated a disconnect between those with clinical knowledge who understand the requirements of assistive devices, and the engineers with the technical knowledge to create such devices [25].
Soft-robotics is an emerging field with capabilities to address the limitations of bulky, rigid and heavy exoskeletons through designing wearable, soft devices that are lightweight, compliant and flexible, resulting in safe human interaction, suitable for body assistance [37, 38]. Soft exoskeletons are different from rigid exoskeletons as they have an interface with the wearer that is a non-rigid structure, for instance, textiles, velcro or straps [39]. A device may also be a hybrid of both, and would therefore not technically be a fully soft exoskeleton (despite sometimes being described as a soft exoskeleton). Examples include an exoskeleton with compliant/soft actuators but a rigid structure-based body attachment, or a system with rigid actuators mounted on the body using a soft structure. A review of 52 lower-limb exoskeletons found that only 11% were fully soft exoskeletons [40]. A recent review on soft wearable robots reported an exponential growth of using pneumatic artificial muscles (PAMs), electrically-driven actuators, and textiles/fabric-based actuators over the past 10 years [41].
If the advantages of soft robotics are to be realised and implemented effectively and transitioned rapidly into clinical and community settings, the engineering and clinical gap must be reduced. Consequently, this state-of-the-art review aims to identify the limitations of existing exoskeletons as perceived by clinicians and patients, and discuss the potential soft-robotic solutions. The review informs FREEHAB, a project which aims to design wearable, assistive soft-robotic devices for people with impaired mobility (project website - The Right Trousers [42]). This collaborative review was undertaken by Freehab researchers with both clinical (LM) and engineering (RSD, NR) expertise, reducing the clinical-engineering disconnect.
The "Methods" section will outline the methods of the review. The "Patient and physiotherapist perceived limitations of exoskeletons" section will discuss the patient and physiotherapist perceived limitations of existing rigid exoskeletons based upon a review of the existing literature. The "Patient and physiotherapist perceived limitations of exoskeletons" section will also introduce potential solutions to these limitations. The "Discussion" section will summarise the main findings in relation to wider literature, and has a wider discussion on future assistive suits and identifies how soft-robotic technologies may provide solutions.
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