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1. Targeting Paretic Propulsion and Walking Speed With a Soft Robotic Exosuit: A Consideration-of-Concept Trial

   https://doi.org/10.3389/fnbot.2021.689577  

   Porciuncula, Franchino; Baker, Teresa C.; Arumukhom Revi, Dheepak; Bae, Jaehyun; Sloutsky, Regina; Ellis, Terry D.; Walsh, Conor J.; Awad, Louis N. (July 2021, Frontiers in Neurorobotics)

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   Background: Soft robotic exosuits can facilitate immediate increases in short- and long-distance walking speeds in people with post-stroke hemiparesis. We sought to assess the feasibility and rehabilitative potential of applying propulsion-augmenting exosuits as part of an individualized and progressive training program to retrain faster walking and the underlying propulsive strategy. Methods: A 54-yr old male with chronic hemiparesis completed five daily sessions of Robotic Exosuit Augmented Locomotion (REAL) gait training. REAL training consists of high-intensity, task-specific, and progressively challenging walking practice augmented by a soft robotic exosuit and is designed to facilitate faster walking by way of increased paretic propulsion. Repeated baseline assessments of comfortable walking speed over a 2-year period provided a stable baseline from which the effects of REAL training could be elucidated. Additional outcomes included paretic propulsion, maximum walking speed, and 6-minute walk test distance. Results: Comfortable walking speed was stable at 0.96 m/s prior to training and increased by 0.30 m/s after training. Clinically meaningful increases in maximum walking speed (Δ: 0.30 m/s) and 6-minute walk test distance (Δ: 59 m) were similarly observed. Improvements in paretic peak propulsion (Δ: 2.80 %BW), propulsive power (Δ: 0.41 W/kg), and trailing limb angle (Δ: 6.2 degrees) were observed at comfortable walking speed ( p 's < 0.05). Likewise, improvements in paretic peak propulsion (Δ: 4.63 %BW) and trailing limb angle (Δ: 4.30 degrees) were observed at maximum walking speed ( p 's < 0.05). Conclusions: The REAL training program is feasible to implement after stroke and capable of facilitating rapid and meaningful improvements in paretic propulsion, walking speed, and walking distance. 

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2. Effects of a soft robotic exosuit on the quality and speed of overground walking depends on walking ability after stroke

   https://doi.org/10.1186/s12984-023-01231-7  

   Sloot, Lizeth H.; Baker, Lauren M.; Bae, Jaehyun; Porciuncula, Franchino; Clément, Blandine F.; Siviy, Christopher; Nuckols, Richard W.; Baker, Teresa; Sloutsky, Regina; Choe, Dabin K.; et al (September 2023, Journal of NeuroEngineering and Rehabilitation)

   Abstract BackgroundSoft robotic exosuits can provide partial dorsiflexor and plantarflexor support in parallel with paretic muscles to improve poststroke walking capacity. Previous results indicate that baseline walking ability may impact a user’s ability to leverage the exosuit assistance, while the effects on continuous walking, walking stability, and muscle slacking have not been evaluated. Here we evaluated the effects of a portable ankle exosuit during continuous comfortable overground walking in 19 individuals with chronic hemiparesis. We also compared two speed-based subgroups (threshold: 0.93 m/s) to address poststroke heterogeneity. MethodsWe refined a previously developed portable lightweight soft exosuit to support continuous overground walking. We compared five minutes of continuous walking in a laboratory with the exosuit to walking without the exosuit in terms of ground clearance, foot landing and propulsion, as well as the energy cost of transport, walking stability and plantarflexor muscle slacking. ResultsExosuit assistance was associated with improvements in the targeted gait impairments: 22% increase in ground clearance during swing, 5° increase in foot-to-floor angle at initial contact, and 22% increase in the center-of-mass propulsion during push-off. The improvements in propulsion and foot landing contributed to a 6.7% (0.04 m/s) increase in walking speed (R² = 0.82). This enhancement in gait function was achieved without deterioration in muscle effort, stability or cost of transport. Subgroup analyses revealed that all individuals profited from ground clearance support, but slower individuals leveraged plantarflexor assistance to improve propulsion by 35% to walk 13% faster, while faster individuals did not change either. ConclusionsThe immediate restorative benefits of the exosuit presented here underline its promise for rehabilitative gait training in poststroke individuals. 

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3. Real-time gait metric estimation for everyday gait training with wearable devices in people poststroke

   https://doi.org/10.1017/wtc.2020.11  

   Arens, Philipp; Siviy, Christopher; Bae, Jaehyun; Choe, Dabin K.; Karavas, Nikos; Baker, Teresa; Ellis, Terry D.; Awad, Louis N.; Walsh, Conor J. (January 2021, Wearable Technologies)

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   Abstract Hemiparetic walking after stroke is typically slow, asymmetric, and inefficient, significantly impacting activities of daily living. Extensive research shows that functional, intensive, and task-specific gait training is instrumental for effective gait rehabilitation, characteristics that our group aims to encourage with soft robotic exosuits. However, standard clinical assessments may lack the precision and frequency to detect subtle changes in intervention efficacy during both conventional and exosuit-assisted gait training, potentially impeding targeted therapy regimes. In this paper, we use exosuit-integrated inertial sensors to reconstruct three clinically meaningful gait metrics related to circumduction, foot clearance, and stride length. Our method corrects sensor drift using instantaneous information from both sides of the body. This approach makes our method robust to irregular walking conditions poststroke as well as usable in real-time applications, such as real-time movement monitoring, exosuit assistance control, and biofeedback. We validate our algorithm in eight people poststroke in comparison to lab-based optical motion capture. Mean errors were below 0.2 cm (9.9%) for circumduction, −0.6 cm (−3.5%) for foot clearance, and 3.8 cm (3.6%) for stride length. A single-participant case study shows our technique’s promise in daily-living environments by detecting exosuit-induced changes in gait while walking in a busy outdoor plaza. 

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4. Exoskeleton gait training on real-world terrain improves spatiotemporal performance in cerebral palsy

   https://doi.org/10.3389/fbioe.2024.1503050  

   Tagoe, Emmanuella A; Fang, Ying; Williams, Jack R; Stone, Julie L; Lerner, Zachary F (December 2024, Frontiers in Bioengineering and Biotechnology)

   IntroductionWalking is essential for daily life but poses a significant challenge for many individuals with neurological conditions like cerebral palsy (CP), which is the leading cause of childhood walking disability. Although lower-limb exoskeletons show promise in improving walking ability in laboratory and controlled overground settings, it remains unknown whether these benefits translate to real-world environments, where they could have the greatest impact. MethodsThis feasibility study evaluated whether an untethered ankle exoskeleton with an adaptable controller can improve spatiotemporal outcomes in eight individuals with CP after low-frequency exoskeleton-assisted gait training on real-world terrain. ResultsComparing post- and pre-assessment, assisted walking speed increased by 11% and cadence by 7% (p= 0.003;p= 0.006), while unassisted walking speed increased by 8% and cadence by 5% (p= 0.009;p= 0.012). In the post-assessment, assisted walking speed increased by 9% and stride length by 8% relative to unassisted walking (p< 0.001;p< 0.001). Improvements in walking speed were more strongly associated with longer strides than higher cadence (R²= 0.92;R²= 0.68). Muscle activity outcomes, including co-contraction of the soleus and tibialis anterior, did not significantly change after training. DiscussionThese findings highlight the spatiotemporal benefits of an adaptive ankle exoskeleton for individuals with CP in real-world settings after short-term training. This work paves the way for future randomized controlled trials (RCTs) to evaluate the isolated effects of adaptive ankle exoskeletons on gait performance and neuromuscular outcomes in individuals with CP in real-world environments 

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5. A Music-Based Digital Therapeutic: Proof-of-Concept Automation of a Progressive and Individualized Rhythm-Based Walking Training Program After Stroke

   https://doi.org/10.1177/1545968320961114  

   Hutchinson, Karen; Sloutsky, Regina; Collimore, Ashley; Adams, Benjamin; Harris, Brian; Ellis, Terry D.; Awad, Louis N. (November 2020, Neurorehabilitation and Neural Repair)

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   Background The rhythm of music can entrain neurons in motor cortex by way of direct connections between auditory and motor brain regions. Objective We sought to automate an individualized and progressive music-based, walking rehabilitation program using real-time sensor data in combination with decision algorithms. Methods A music-based digital therapeutic was developed to maintain high sound quality while modulating, in real-time, the tempo (ie, beats per minute, or bpm) of music based on a user’s ability to entrain to the tempo and progress to faster walking cadences in-sync with the progression of the tempo. Eleven individuals with chronic hemiparesis completed one automated 30-minute training visit. Seven returned for 2 additional visits. Safety, feasibility, and rehabilitative potential (ie, changes in walking speed relative to clinically meaningful change scores) were evaluated. Results A single, fully automated training visit resulted in increased usual (∆ 0.085 ± 0.027 m/s, P = .011) and fast (∆ 0.093 ± 0.032 m/s, P = .016) walking speeds. The 7 participants who completed additional training visits increased their usual walking speed by 0.12 ± 0.03 m/s after only 3 days of training. Changes in walking speed were highly related to changes in walking cadence ( R 2 > 0.70). No trips or falls were noted during training, all users reported that the device helped them walk faster, and 70% indicated that they would use it most or all of the time at home. Conclusions In this proof-of-concept study, we show that a sensor-automated, progressive, and individualized rhythmic locomotor training program can be implemented safely and effectively to train walking speed after stroke. Music-based digital therapeutics have the potential to facilitate salient, community-based rehabilitation. 

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