Edwin H.F. van Asseldonk

Comparison of different methods to identify and quantify balance control

The goal of this paper is to clarify the methodological aspects of studies of human balance during quiet standing and perturbed standing. Centre of mass (CoM), centre of pressure (CoP) and electromyogram (EMG) or similar measures are commonly recorded to quantify human balance control. In this paper we show that to identify the rigid body dynamics and the physiological mechanism that controls the body separately, one has to externally perturb the body with known perturbations and to use the indirect (IA) or joint input–output approach (JA) for identification. However, in many balance control studies the direct approach (DA) have been used, which is well suited to study open-loop systems but will give erroneous results when applied to a closed-loop system, as in human balance control. The cross-correlation function and linear regression are examples of the erroneous application of the DA approach in human balance control studies. The consequences of this erroneous DA are given. In addition a new application of the JA is presented that identifies physiological mechanisms that control balance, including passive and active feedback pathways. This new method is compared with existing identification schemes that use the IA and an existing JA that estimates the active pathway. Also it is shown how descriptive measures such as the power spectral densities (PSD) or the stabilogram diffusion plot (SDP) of the CoP and/or CoM depends on the PSD of internal perturbations and sensor noise, which are not measured. Although descriptive measures can be used to describe the state of the balance control system for a particular situation, it does not separate the dynamics of unknown processes that perturb balance from the dynamics of the active and passive feedback mechanisms that controls balance. Only the IA and the preferred JA can give estimates of the passive and active passive feedback mechanisms that control balance.

Oscillator-based assistance of cyclical movements: model-based and model-free approaches.

In this article, we propose a new method for providing assistance during cyclical movements. This method is trajectory-free, in the sense that it provides user assistance irrespective of the performed movement, and requires no other sensing than the assisting robot’s own encoders. The approach is based on adaptive oscillators, i.e., mathematical tools that are capable of learning the high level features (frequency, envelope, etc.) of a periodic input signal. Here we present two experiments that we recently conducted to validate our approach: a simple sinusoidal movement of the elbow, that we designed as a proof-of-concept, and a walking experiment. In both cases, we collected evidence illustrating that our approach indeed assisted healthy subjects during movement execution. Owing to the intrinsic periodicity of daily life movements involving the lower-limbs, we postulate that our approach holds promise for the design of innovative rehabilitation and assistance protocols for the lower-limb, requiring little to no user-specific calibration.

The Effects on Kinematics and Muscle Activity of Walking in a Robotic Gait Trainer During Zero-Force Control

“Assist as needed” control algorithms promote activity of patients during robotic gait training. Implementing these requires a free walking mode of a device, as unassisted motions should not be hindered. The goal of this study was to assess the normality of walking in the free walking mode of the LOPES gait trainer, an 8 degrees-of-freedom lightweight impedance controlled exoskeleton. Kinematics, gait parameters and muscle activity of walking in a free walking mode in the device were compared with those of walking freely on a treadmill. Average values and variability of the spatio-temporal gait variables showed no or small (relative to cycle-to-cycle variability) changes and the kinematics showed a significant and relevant decrease in knee angle range only. Muscles involved in push off showed a small decrease, whereas muscles involved in acceleration and deceleration of the swing leg showed an increase of their activity. Timing of the activity was mainly unaffected. Most of the observed differences could be ascribed to the inertia of the exoskeleton. Overall, walking with the LOPES resembled free walking, although this required several adaptations in muscle activity. These adaptations are such that we expect that Assist as Needed training can be implemented in LOPES.

Design and Control of the MINDWALKER Exoskeleton

Powered exoskeletons can empower paraplegics to stand and walk. Actively controlled hip ab/adduction (HAA) is needed for weight shift and for lateral foot placement to support dynamic balance control and to counteract disturbances in the frontal plane. Here, we describe the design, control, and preliminary evaluation of a novel exoskeleton, MINDWALKER. Besides powered hip flexion/extension and knee flexion/extension, it also has powered HAA. Each of the powered joints has a series elastic actuator, which can deliver 100 Nm torque and 1 kW power. A finite-state machine based controller provides gait assistance in both the sagittal and frontal planes. State transitions, such as stepping, can be triggered by the displacement of the Center of Mass (CoM). A novel step-width adaptation algorithm was proposed to stabilize lateral balance. We tested this exoskeleton on both healthy subjects and paraplegics. Experimental results showed that all users could successfully trigger steps by CoM displacement. The step-width adaptation algorithm could actively counteract disturbances, such as pushes. With the current implementations, stable walking without crutches has been achieved for healthy subjects but not yet for SCI paraplegics. More research and development is needed to improve the gait stability.

Disentangling the contribution of the paretic and non-paretic ankle to balance control in stroke patients

During stroke recovery, restoration of the paretic ankle and compensation in the non-paretic ankle may contribute to improved balance maintenance. We examine a new approach to disentangle these recovery mechanisms by objectively quantifying the contribution of each ankle to balance maintenance. Eight chronic hemiparetic patients were included. Balance responses were elicited by continuous random platform movements. We measured body sway and ground reaction forces below each foot to calculate corrective ankle torques in each leg. These measurements yielded the Frequency Response Function (FRF) of the stabilizing mechanisms, which expresses the amount and timing of the generated corrective torque in response to sway at the specified frequencies. The FRFs were used to calculate the relative contribution of the paretic and non-paretic ankle to the total amount of generated corrective torque to correct sway. All patients showed a clear asymmetry in the balance contribution in favor of the non-paretic ankle. Paretic balance contribution was significantly smaller than the contribution of the paretic leg to weight bearing, and did not show a clear relation with the contribution to weight bearing. In contrast, a group of healthy subjects instructed to distribute their weight asymmetrically showed a one-on-one relation between the contribution to weight bearing and to balance. We conclude that the presented approach objectively quantifies the contribution of each ankle to balance maintenance. Application of this method in longitudinal surveys of balance rehabilitation makes it possible to disentangle the different recovery mechanisms. Such insights will be critical for the development and evaluation of rehabilitation strategies.

Ambulatory estimation of foot placement during walking using inertial sensors

This study proposes a method to assess foot placement during walking using an ambulatory measurement system consisting of orthopaedic sandals equipped with force/moment sensors and inertial sensors (accelerometers and gyroscopes). Two parameters, lateral foot placement (LFP) and stride length (SL), were estimated for each foot separately during walking with eyes open (EO), and with eyes closed (EC) to analyze if the ambulatory system was able to discriminate between different walking conditions. For validation, the ambulatory measurement system was compared to a reference optical position measurement system (Optotrak). LFP and SL were obtained by integration of inertial sensor signals. To reduce the drift caused by integration, LFP and SL were defined with respect to an average walking path using a predefined number of strides. By varying this number of strides, it was shown that LFP and SL could be best estimated using three consecutive strides. LFP and SL estimated from the instrumented shoe signals and with the reference system showed good correspondence as indicated by the RMS difference between both measurement systems being 6.5 ± 1.0 mm (mean ± standard deviation) for LFP, and 34.1 ± 2.7 mm for SL. Additionally, a statistical analysis revealed that the ambulatory system was able to discriminate between the EO and EC condition, like the reference system. It is concluded that the ambulatory measurement system was able to reliably estimate foot placement during walking.

Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review

Purpose. To investigate the effect of different aspects and types of augmented feedback on motor functions and motor activities of the hemiparetic arm after stroke. Method. Systematic search of the scientific literature was performed in the Pubmed and Cochrane database from 1975 to March 2009. The augmented feedback used in the intervention was classified with respect to aspects (nature, timing and frequency) and types (auditory, sensory and visual). Results. The systematic literature search resulted in 299 citations. On the basis of inclusion and exclusion criteria, 23 full-text articles were included for analysis. There are some trends in favour of providing augmented knowledge of performance feedback, augmented auditory and combined sensory and visual feedback. No consistent effects on motor relearning were observed for summary or faded, terminal or concurrent, solely visual or solely sensory augmented feedback. Conclusions. On the basis of this study, it was not possible to determine which combinations of aspects and types of augmented feedback are most essential for a beneficial effect on motor activities and motor functions of the hemiparetic arm after stroke. This was due to the combination of multiple aspects and types of augmented feedback in the included studies. This systematic review indicates that augmented feedback in general has an added value for stroke rehabilitation.

Influence of haptic guidance in learning a novel visuomotor task

In (re)learning of movements, haptic guidance can be used to direct the needed adaptations in motor control. Haptic guidance influences the main driving factors of motor adaptation, execution error, and control effort in different ways. Human-control effort is dissipated in the interactions that occur during haptic guidance. Minimizing the control effort would reduce the interaction forces and result in adaptation. However, guidance also decreases the magnitude of the execution errors, which could inhibit motor adaptation. The aim of this study was to assess how different types of haptic guidance affect kinematic adaptation in a novel visuomotor task. Five groups of subjects adapted to a reaching task in which the visual representation of the hand was rotated 30 degrees. Each group was guided by a different force field. The force fields differed in magnitude and direction in order to discern the adaptation based on execution errors and control effort. The results demonstrated that the execution error did indeed play a key role in adaptation. The more the guiding forces restricted the occurrence of execution errors, the smaller the amount and rate of adaptation. However, the force field that enlarged the execution errors did not result in an increased rate of adaptation. The presence of a small amount of adaptation in the groups who did not experience execution errors during training suggested that adaptation could be driven on a much slower rate and on the basis of minimization of control effort as was evidenced by a gradual decrease of the interaction forces during training. Remarkably, also in the group in which the subjects were passive and completely guided, a small but significant adaptation occurred. The conclusion is that both minimization of execution errors and control effort drives kinematic adaptation in a novel visuomotor task, but the latter at a much slower rate.

Ankle-foot orthoses in stroke: Effects on functional balance, weight-bearing asymmetry and the contribution of each lower limb to balance control

BACKGROUND Ankle-foot orthoses are often provided to improve walking in stroke patients, although the evidence of effects on walking and balance control is still inconsistent. This could be caused by a lack of insight into the influence of orthoses on the underlying impairments. These impairments can be assessed with dual plate posturography to determine the relative contribution of each lower limb to balance control and weight-bearing. This study examined the effects of ankle-foot orthoses on functional balance, static and dynamic weight-bearing asymmetry and dynamic balance control of the paretic and non-paretic lower limbs. METHODS Twenty stroke subjects (time since stroke 5-127 months) completed the study. Subjects were assessed with and without ankle-foot orthosis. Functional balance was assessed using the Berg Balance Scale, Timed Up & Go test, Timed Balance Test, 10-m walking test and Functional Ambulation Categories. Weight-bearing asymmetry and dynamic balance control were assessed with force plates on a movable platform. FINDINGS No significant effects of ankle-foot orthoses were found for weight-bearing asymmetry and dynamic balance control, but significant differences in favour of ankle-foot orthosis use were found for most functional tests. INTERPRETATION Although ankle-foot orthoses had no effect on weight-bearing asymmetry or dynamic balance contribution of the paretic lower limb, functional tests were performed significantly better with orthoses. Apparently, improvements at functional level cannot be readily attributed to a greater contribution of the paretic lower limb to weight-bearing or balance control. This finding suggests that ankle-foot orthoses influence compensatory mechanisms.

Fixating the pelvis in the horizontal plane affects gait characteristics

In assistive devices for neuro-rehabilitation, natural human motions are partly restricted by the device. This may affect the normality of walking during training. This research determines effects on gait of fixating the pelvis translations in the horizontal plane during treadmill walking. Direct effects on the motion of the pelvis and external forces acting on the pelvis were measured. Several gait descriptors (step parameters, trunk angles and a ground reaction force parameter) were defined and measured to indicate changes. We observed the effect of the pelvis fixation on these parameters while varying gait velocity (0.35, 0.60 and 0.90 m/s). It was shown that the fixation caused a reduction of step width by 33%, and an increase of step length of 19%. Sagittal and coronal trunk rotations changed with +68% and -54% respectively. The fixation also significantly changed the effect of speed on most descriptors. It can therefore be concluded that a fixation of the pelvis severely affects gait dynamics and that it should be avoided if natural walking should be possible during training.