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Robotic exoskeletons are designed to assist patients with motor dysfunctions. Recent researches focus on extending the robotic assistance to patient activities other than ground level walking. This study aims to analyse the lower limb muscle activity during inclined slope walking contrasting with that of ground level walking. Two different angles of inclination were chosen: 9 degrees and 18 degrees. 9 degrees inclined slope is the universal ramp size for wheelchairs. The hypothesis is that muscle activation, and ultimately metabolic cost, in inclined slope walking is different from that of ground level walking. Collected motion data and simulation in OpenSim prove that the difference in metabolic cost is because of increased activity of ankle dorsiflexors and hip extensors and reduced activity of knee extensors. Finally, muscle activities along with other criteria such as kinematic alignment and joint range of motion are summed up as biomechanical considerations for robotic exoskeleton design.

Purpose: To evaluate the use of the GoBack-catheter (Upstream Peripheral Technologies) in complex revascularizations in lower limb arteries. Materials and Methods: In this retrospective single-center study, the results of the first 100 consecutive patients including 101 limb-revascularizations, performed between May 2018 and July 2020 with the study device, were analyzed. In all cases, guidewire-crossing failed, and all lesions were chronic total occlusions (CTO), either de novo, reocclusions, or in-stent reocclusions. Successful crossing was defined as passing the CTO using the study device. Patency at discharge and after 30 days was defined as less than 50% restenosis on duplex sonography, without target lesion revascularization. Results: Median lesion length was 24 cm and 38 patients (37.6%) had a calcium grading according to the peripheral arterial calcium scoring system (PACSS) of 4 or 5. In 20.8% of patients, an occluded stent was treated. CTOs involved the femoropopliteal segment in 91.1%, iliac arteries in 5.9%, and tibial arteries in 7.9%. The GoBackcatheter was employed for entering into or crossing through parts or the full length of a CTO or an occluded stent as well as for re-entering into the true lumen after subintimal crossing. The device was used via contralateral and ipsilateral antegrade as well as retrograde access with an overall technical success rate of 92.1%. In 3 patients minor bleeding occurred at the crossing or re-entry site, which were managed conservatively. Thirty-day adverse limb events comprised minor amputations in 4 patients (4.0%), 1 major amputation (1.0%), and reocclusions in 7 limbs (6.9%). Conclusion: The new GoBack-catheter offers versatile endovascular applicability for complex CTO recanalization in a broad range of peripheral vascular interventions with a high technical success and low complication rate.

Background: The number of people with diabetes is rising globally, and they are at higher risk of foot complications that can ultimately result in lower limb amputation. Additionally, individuals with diabetes whoundergo amputation are more likely to lose the contralateral limb. Consistent care and preventive measuresare crucial for reducing the risk of further amputations. Aim: This study aims to explore the current experience of certified prosthetist and orthotist in Denmarkconcerning the assessment of the contralateral limb in individuals with diabetes who utilize a lower limbprosthesis. Method: A qualitative study with an exploratory research design was conducted. Thematic analysis, using aninductive approach was employed to analyze data from eight semi-structured interviews with CPOs from Denmark. Findings: The analysis of the interview results revealed three main themes - responsibility, prioritization,and barriers - which frequently overlap. Each theme had multiple sub-themes which highlights the variationin the participants’ experiences. Conclusion: The variation in responses gathered from the interviews unveiled diverse perspectives on responsibility, prioritization, and barriers which points to a lack of clear guidelines in the Danish healthcaresystem regarding this assessment of the contralateral limb in this patient group. This study offers novel insightsinto the diverse experiences and decision-making processes of Danish CPOs when it comes to the contralaterallimb assessment in diabetic foot care. / <p></p><p></p>

Yes / Background: Falls on stairs are a common and dangerous problem for older people. This series of studies evaluated whether or not selected changes to the appearance of stairs could make them safer for older people to negotiate. Objectives: To determine the effect of (1) a step edge highlighter and its position and (2) an optimised horizontal–vertical (H–V) visual illusion placed on a step riser on gait safety during stair descent and ascent. Design: A series of studies using a repeated measures, laboratory-based design, investigating gait control and safety in independently mobile older people. Setting: The University of Bradford Vision and Mobility Laboratory. Participants: Fit and healthy older people aged 60 years of age or more, independently mobile, reasonably active and with normal healthy eyes and corrected vision. Interventions: A step edge highlighter in a variety of offsets from the stair edge and an optimised H–V visual illusion placed on the stair riser. The H–V illusion was provided on a staircase by horizontal step edge highlighters on the tread edges and vertical stripes on the step risers. Main outcome measures: Gait parameters that are important for safe stepping in ascent and descent, particularly toe clearance during stair ascent and heel clearance during stair descent. Results: The step edge highlighter increased the precision of heel clearance during stepping and its positioning relative to the tread edge determined the extent of heel clearance over the tread edge. Positioning the highlighter away from the tread edge, as is not uncommonly provided by friction strips, decreased heel clearance significantly and led to greater heel scuffs. Although psychophysics experiments suggested that higher spatial frequencies of the H–V illusion might provide greater toe clearance on stair ascent, gait trials showed similar increased toe clearances for all spatial frequencies. When a 12 cycle per step spatial frequency H–V illusion was used, toe clearance increases of approximately 1 cm (17.5%) occurred without any accompanying changes in other important gait parameters or stability measures. Conclusions: High-contrast tread edge highlighters present on steps and stairs and positioned flush with the edge of the tread or as near to this as possible should improve stair descent safety in older people. A H–V illusion positioned on the riser of a raised surface/walkway (e.g. kerbs) and/or the top and/or bottom of a stairway is likely to increase foot clearance over the associated step/stair edge, and appears not to lead to any decrement in postural stability. Thus, their use is likely to reduce trip risk and hence improve stair ascent safety. The effect of the step and stair modifications should be assessed in older people with visual impairment. The only other remaining assessment that could be made would be to assess fall prevalence on steps and stairs, perhaps in public buildings, with and without these modifications. / National Institute for Health Research, Public Health Research programme. PHR programme as project number 10/3009/06

Dans l’hémiparésie consécutive à un AVC, une coactivation anormale des extenseurs du genou et de la cheville est souvent observée à la jambe atteinte lorsque la personne tente de bouger ou encore lors de la marche. Les mécanismes sous-jacents à cette coactivation sont mal compris. Bien que l’AVC entraîne une lésion supraspinale, des évidences démontrent le dysfonctionnement de certains circuits spinaux dans l’hémiparésie. Ce projet de doctorat visait à évaluer : 1) l’excitabilité des circuits spinaux intersegmentaires projetant des extenseurs du genou aux extenseurs de la cheville et 2) si un éventuel dysfonctionnement de ces circuits dans l’hémiparésie est associé à une coactivation anormale des extenseurs du genou et de la cheville lors de contractions statiques et au cours de la marche. La première étude compare la modulation de l’activité réflexe du soléaire suite à la stimulation du nerf fémoral entre des sujets hémiparétiques et sains. Une augmentation de la facilitation hétéronyme de courte latence et une diminution de l’inhibition ultérieure du réflexe H du soléaire ont été observées chez les sujets hémiparétiques. Ces résultats démontrent un dysfonctionnement des circuits intersegmentaires propriospinaux liant le quadriceps au soléaire suite à l’AVC. La deuxième étude démontre que ces changements dans la modulation hétéronyme des sujets hémiparétiques, évaluée au moyen de la méthode complexe basée sur l’activité réflexe du soléaire, sont similaires à ceux observés lorsque la modulation est évaluée en utilisant une méthode plus simple, soit celle de l’activité volontaire du soléaire. De plus, la modulation hétéronyme évaluée par les deux méthodes est corrélée avec l’atteinte motrice à la jambe parétique. La troisième étude a permis de quantifier une augmentation de la coactivation entre les extenseurs du genou et de la cheville lors de contractions volontaires statiques chez des personnes hémiparétiques par rapport à des personnes saines. De plus, le niveau accru de la coactivation involontaire des extenseurs de la cheville lors de l’activation volontaire des extenseurs du genou s’avère corrélé avec la modulation intersegmentaire du côté parétique. La quatrième étude a utilisé un indice temporel, soit l’intervalle entre les pics d’activation électromyographique (PAI), et un indice d’amplitude de coactivation (CAI) pour quantifier une augmentation de la coactivation entre les extenseurs du genou et de la cheville lors de la marche chez des personnes hémiparétiques par rapport à des personnes saines. Ces indices sont corrélés, pour certains groupes musculaires, avec la modulation intersegmentaire modifiée du côté parétique. Finalement, des résultats préliminaires montrent que la vibration mécanique du tendon rotulien (80 Hz) réduit la facilitation intersegmentaire accrue des sujets hémiparétiques. Ce projet doctoral a permis de mettre en lumière un dysfonctionnement de circuits spinaux liant le quadriceps et le soléaire dans l’hémiparésie consécutive à un AVC. Ce changement dans les mécanismes neurophysiologiques de la moelle épinière est corrélé avec des changements fonctionnels. Ainsi, ce dysfonctionnement pourrait contribuer à la coactivation involontaire entre les extenseurs du genou et de la cheville qui fait partie intégrante de la synergie pathologique en extension souvent rencontrée à la jambe parétique lors d’efforts en statique et pendant la marche. Finalement, une étude préliminaire suggère que la vibration mécanique serait une modalité sensorielle prometteuse pour réguler l’hyperexcitabilité des circuits spinaux qui contribuerait aux atteintes motrices chez les personnes hémiparétiques. / In stroke individuals, an abnormal coactivation of knee and ankle extensors is often observed when the paretic leg is voluntarily moved and during gait. The mechanisms underlying this abnormal coactivation are not well understood. Although, stroke is the result of a supraspinal lesion, studies have shown that spinal pathways might also be affected in hemiparesis. This doctoral project aims: 1) to assess intersegmental pathways projecting from knee extensors to ankle extensors in hemiparetic patients and 2) to evaluate whether a potential malfunction in these pathways after stroke is associated with an abnormal coactivation of leg extensors during static contractions and during gait. The first study of this project compares the effects of femoral nerve (FN) stimulation on soleus reflex activity in hemiparetic patients and healthy individuals. An increase of the early short-latency heteronymous facilitation and a decrease of the later inhibition of soleus H reflex induced by FN stimulation were observed in stroke patients. These results demonstrate the malfunction of intersegmental short propriospinal pathways linking quadriceps to soleus after stroke. The second study shows that these changes in the heteronymous modulation assessed with the complex method using soleus H reflex are similar to those found using a simpler method based on the modulation of soleus voluntary EMG. Moreover, changes in the propriospinal modulation observed with both methods were correlated with motor impairments of the paretic leg. The third study has quantified an increased coactivation of knee and ankle extensors during static contractions in stroke patients compared to healthy controls. Furthermore, the increased coactivation of ankle extensors during the voluntary contraction of knee extensors was related to the modified heteronymous modulation in the paretic leg. The fourth study has quantified an increased coactivation of knee and ankle extensors in hemiparetic gait using a temporal coactivation index, that was the peak activation interval (PAI) and a coactivation amplitude index (CAI). In some muscles, these indexes were correlated to the modified intersegmental modulation of soleus voluntary activity on the paretic side of stroke patients. Finally, preliminary results have shown that vibration of the patellar tendon (80 Hz) can reduce the enhanced heteronymous facilitation observed in the paretic leg. This doctoral project demonstrates the malfunction of intersegmental pathways linking quadriceps to soleus in hemiparesis following stroke. The neurophysiological alterations at the spinal level are correlated with functional changes. This malfunction could contribute to the abnormal involuntary coactivation of knee and ankle extensors often observed in the paretic leg while the person attempts to move or during gait. Finally, a preliminary study indicates that mechanical vibration could be a promising sensory modality in the regulation of the hyperexcitability of spinal reflex pathways, which is thought to participate in motor impairments after stroke.

Title: Appropriateness of choice to walk or run, depending on the speed of a quick relocation with load carriage Objectives: Comparison of physiological response of organism during the walk and run at speed 6 - 7,4 km.h-1 with carried load 15 kg with follow-up determination of critical speed in connection with economy of these activities where there were discovered sizes of correlation with proportional representation of fat free mass and working length of lower limb. Methods: The method applied in this research was the quantitative research based on intra-individual and inter-individual comparative analysis. Results: Based on the measured data it has been found out that there is a critical speed at 7,43 km.h-1 (±0,53), with respect to economy of walk compared to run with 15 kg load. The average heart rate during the critical speed was 129 BPM (±9,67). The average energy expenditure per minute during the critical speed was 11,9 kcal (±2,04). In addition there were discovered sizes of correlation between critical speed and the working length of lower limb where rP = 0,9203 was statiscitally significant. (α = 0,05) and between critical speed and proportional representation of fat free mass, where rP = 0,1529 was not found to be statistically significant (α = 0,05). Keywords: quick relocation, load...

Les problèmes neurologiques dus aux AVC et aux lésions de la moelle épinière ainsi que la faiblesse des muscles squelettiques peuvent considérablement affecter les capacités motrices des personnes infirmes ou âgées. Les solutions traditionnellement utilisées pour l’assistance et le traitement de ces personnes dépendantes, sont relativement coûteuses; en termes de prise charge, elles impliquent, pour les aidants et les services de santé, des efforts humains et des moyens financiers importants. Dans ce cadre, la robotique apparaît comme une solution bien adaptée et prometteuse pour développer des systèmes d’assistance permettant d’améliorer l’autonomie des personnes dépendantes. Les exosquelettes des membres inférieurs sont des robots portables, destinés à être utilisés en tant que dispositifs d’aide à la mobilité pour augmenter les capacités motrices des sujets porteurs, ou comme auxiliaires de rééducation neuromusculaire. Ce domaine de recherche a fait l’objet, ces dernières années, d’un intérêt grandissant au sein de la communauté robotique. Du fait qu’un exosquelette est caractérisé par une interaction physique et cognitive directe avec son porteur, sa fonction principale est de fournir une assistance adaptée aux capacités sensorimotrices du sujet porteur. Il est, par conséquent, nécessaire de développer des stratégies de commande basées sur l’intention de mouvement du porteur. Du point de vue de l’exosquelette, les contacts physiques avec le sujet porteur ou l’environnement sont considérés comme des perturbations affectant la bonne réalisation des mouvements désirés du porteur. Ces perturbations doivent être également être prises en compte lors de la conception des stratégies de commande.Dans cette thèse, nous proposons trois stratégies de commandes assistives pour les exosquelettes des membres inférieurs. Deux modes d’assistance sont étudiés ici: le mode passif où le sujet dispose de capacités motrices très limitées et ne développe quasiment aucun effort, et le mode actif-aidé où le sujet possède certaines capacités motrices mais qui sont insuffisantes pour réaliser de manière autonome un mouvement désiré. Dans la première stratégie de commande, le sujet est supposé être en mode passif. Une commande robuste par modes glissants, basée sur un observateur non-linéaire de perturbations (Nonlinear Disturbance Observer (NDO)), est développée pour garantir un suivi précis des mouvements désirés de l’articulation du genou. Dans la deuxième stratégie de commande, nous proposons une structure de commande en impédance active non-linéaire où le sujet est supposé être en mode actif-aidé. Cette stratégie de commande assistive est utilisée pour assister le porteur dans la réalisation d’activités physiques mono-tâche. L’évaluation des performances de la structure proposée sont étudiées dans le cadre de deux activités: la flexion/extension du genou et le transfert assis-debout. Enfin, la troisième stratégie de commande proposée est une commande contextualisée pour assister le porteur dans ses activités de marche. Nous proposons une approche permettant de détecter le mode de marche dès le début d’un nouveau pas, en utilisant les caractéristiques cinématiques du porteur, à savoir la position et la vitesse des pieds lors de la marche. L’approche de détection du mode de marche rend possible la sélection des modèles cinématique et cinétique appropriés pour chaque mode. Différentes stratégies d’assistance sont développées: compensation partielle de la gravité, assistance basée impédance de type ressort/amortisseur virtuel et assistance de type impédance nulle. Ces stratégies sont combinées différemment selon le mode de marche estimé. Pour évaluer les performances des stratégies de commande proposées, deux prototypes d’exosquelettes des membres inférieurs ont été développés: l’exosquelette de l’articulation du genou EICOSI, et l’exosquelette des membres inférieurs E-ROWA / Neurological problems caused by stroke and spinal cord injury as well as the weakness of skeletal muscles may considerably affect the motor ability of the elderly and infirm. Traditional solutions of assistance and treatment for these dependent people are relatively costly; they generally need significant human efforts and financial resources from caregivers and national healthcare centers. In this context, robotics appears as a convenient and promising solution to develop assistive systems for improving the autonomy of dependent people. Lower limb exoskeletons are wearable robots that can be used as assistive devices for augmenting the wearer’s motor ability and/or improving the effectiveness of neuromuscular rehabilitation. Recently, they have attracted increasing interest in the robotics community. As lower limb exoskeletons exhibit close cognitive and physical interactions with the wearer, a fundamental function is to provide appropriate power assistance by taking into account the wearer’s sensor-motor ability. Consequently, it is of great importance to develop human intention based control strategies. Meanwhile, from the exoskeleton’s viewpoint, the physical contacts with the wearer and the environment are both considered disturbances affecting the accomplishment of the wearer’s desired movements. These disturbances should also be taken into account during the design of control strategies.In this thesis, we develop three assistive control strategies for lower limb exoskeletons. In the meantime, two modes of assistance are studied: the passive mode in which the wearer has very limited motor ability as well as the active-assisted mode in which the wearer has certain motor ability but that is insufficient to perform autonomously a desired physical movement. In the first control strategy, the wearer is assumed to be in passive mode. A robust sliding mode control approach is developed based on the use of a nonlinear disturbance observer, in order to guarantee accurate tracking performance of desired knee joint movements. In the second control strategy, we propose a human intention based nonlinear active impedance control structure, in which the wearer is in an active-assisted mode. This assistive strategy is used to assist the wearer in single-task physical activities, for instance, the knee joint flexion/ extension movement. We investigate the performance of the proposed control structure based on two case studies: knee-joint flexion/extension movements and sit-to-stand movements. Finally, the third control strategy is developed to assist the wearer during walking activities. We propose a new approach that is able to detect the gait mode at the early beginning of a new step using the kinematic features namely velocity and position of the wearer’s feet during walking. The proposed gait mode detection approach makes it possible to select appropriate kinematic and kinetic models for each gait mode. Different assistive strategies are developed: partial gravity compensation, virtual-spring/damper based impedance assistance and zero impedance assistance. These strategies are combined differently according to the estimated wearer’s gait mode. To evaluate the proposed control strategies, two lower limb exoskeleton prototypes are developed: a knee joint lower limb exoskeleton, called EICOSI, and a full lower limb exoskeleton, called E-ROWA

Although dynamic prosthetic alignment is an important process for the rehabilitation of transtibial amputees, such alignment technique is subjective and inconsistent. Using biomechanical variables and questionnaire assessments, this study compared an instrument-assisted dynamic alignment technique using the Compas™ system and conventional alignment techniques on nine adults with unilateral transtibial amputation. A focus group discussion was conducted with six prosthetists to understand clinical practice of dynamic alignment and their perception of the Compas™ system. Results found that Compas™ produced more anterior weight line displacement and greater varus moment on the prosthesis than conventional alignment techniques. Alignment changes did not affect pelvic acceleration, and the instrument-assisted alignment technique produced certain biomechanical changes but not necessarily better alignments. Although the current version of the Compas™ system is not clinically feasible, it can be used as a teaching/justification tool. Further investigation with larger sample size and ankle alignment or moment measures is needed.

Although dynamic prosthetic alignment is an important process for the rehabilitation of transtibial amputees, such alignment technique is subjective and inconsistent. Using biomechanical variables and questionnaire assessments, this study compared an instrument-assisted dynamic alignment technique using the Compas™ system and conventional alignment techniques on nine adults with unilateral transtibial amputation. A focus group discussion was conducted with six prosthetists to understand clinical practice of dynamic alignment and their perception of the Compas™ system. Results found that Compas™ produced more anterior weight line displacement and greater varus moment on the prosthesis than conventional alignment techniques. Alignment changes did not affect pelvic acceleration, and the instrument-assisted alignment technique produced certain biomechanical changes but not necessarily better alignments. Although the current version of the Compas™ system is not clinically feasible, it can be used as a teaching/justification tool. Further investigation with larger sample size and ankle alignment or moment measures is needed.