AT for Locomoter Disabilities

By: Dr. Prasanna Lenka & Dr. Robert Reiner


Anil Prabhakar: The EMPOWER conference is something that we came up with an idea three years ago in 2018. And as you heard in the morning Mr. Balakrishnan talking about it, we are now in the third edition. Unfortunately last year we were not able to do it. Now with each edition we have been changing the way or the topics appeared looking at and this time, one of the topics that we thought would be useful is to focus on locomotor disability, but also to look at a lot of devices and that is sort of the session that we are having today. It is a challenge under normal circumstances we would have had demonstrations prototypes. And unfortunately, because of the pandemic, we are being forced to do this online. But I’m hoping that with our speakers today, we will actually get a good opportunity to understand the kinds of devices that are available for persons with motor impairments.


In addition, later this evening, we will have another session on wearable technologies and the two sessions are actually interchangeable and complementary because it’s hard to think of prosthetics without being wearable. So again, although the two sessions have been separated out, given the constraints of being online, we have managed to find our speakers.


Our first speaker this session is Dr. Prasanna Lenka. He is the head of the department at the Department of Prosthetics and Orthotics. He’s also in charge of the Department of Rehabilitation Engineering at the National Institute for Locomotor Disabilities. I first was introduced to Professor Lanka a few years ago at their conference in the Northeast. until such a time I was not actually clued in and that goes to show how there are pockets of accidents happening across the country. And these conferences help us come together, interact and learn from each other.


The second talk in this session will be contributed paper from the National Institute of Speech and Hearing and I’m hoping that by then the speakers would have joined the call. And finally, the last talk is another invited talk by Professor Reiner from will be joining us from Zurich.


So we have had to change the order a little bit to accommodate Professor Reiners scheduled in Europe. But overall I’m expecting that we will have a very good session. So with that brief introduction I request Dr. Lenka to kindly start his presentation.


Prof Lenka: Thank you. Thank you to all the organizing members for such a wonderful program which will really be beneficial to our organization, our department, our ministry, and our total public. It is really because of time constraints that we will focus on the topic itself. So I’ll go to the topic directly without spending anytime.


Basically, I am from the department where we are implementing agency or service providers to persons with locomotor disabilities. Although we have some training programs like physiotherapy, prosthetic orthotics, we have engineering certificate courses. But our major area of focus is to implement the service required for personal disability. We have direct service provider or you can say we are in touch with the hospital where the treatment program is being undertaken by Government of India. So different institutes or NGOs, GOs or regional centers. I’ve already been introduced, so may I go to the topic?


Mr Anil: Yeah.


Prof Lenka: So I hope it will be a series of discussion and talk on technology and disabilities.


There is no alternative but there is no ambiguity in this regard. Technology can make life easier, especially for people with disabilities. It is essential. These essential pieces of information knowledge, you can say without technology, are very difficult nowadays to rehabilitate the disabled persons on that expectation under development throughout the world.


Keeping all in view, these are the right time or you can say a little bit late also, we have to focus on assistive technology, necessarily as per the definition of prescribed definition. We may say any item may be physical, maybe virtual. It may be a piece of equipment or itself with complete product, whether acquired commercially or customized or modified or fabricated by taking the person’s choice to increase or to maintain the functional capability of an individual with the disability. So there are two things: one is to improve the functional capability. One is to restore functional capability if there is a loss. So it is in many ways useful to the person so disability or for rehabilitation.


For example: if I say, what is ability? It’s nothing new. As per the American Paralympic champions, Stoogeman won the silver medal with a right-hand transfemoral amputation compared to a normal person. That means they’re more able, they have shown more ability, they have excellence in different ways. There are many examples where you will find the ability to not be compromised based on their disability.


The same example can be seen for runners with prosthetics. It has been seen, has been documented. It has been tested that people who have bilateral transmetatarsal amputation or bilateral loss of the limb below the knee, run faster than normal people in prosthetic runner blades. So prosthetic runner blade the personal design was himself an amputee: Phillips. He thought why the amputated person cannot play football, cannot play cricket, or got wrong. So he came up with the saying ‘problem is the mother of all invention’. Need is the mother of all inventions. He is the person who designed the runner blade and now that is very successful. Still, we are also using your cases related to sports.


The National scenario is similar. If I go back to the census of 2011 we have a population of around 2.21% of the total population as the disabled. Out of them, almost 50 lakhs required mobility aids and around 40 lakhs from the other source also require some kind of mobility. During the survey people generally considered those who are disabled are those who are not able to walk. They are considered disabled but it has been observed that geriatric cases, old age, diabetics, hemiplegia, and a lot of neurological cases are also considered or they are also certified as disabled. So if it’s expected the percentage will increase in the 2016 population. therefore, around 100 lakhs of assistive technology assistive device that is required for the present population or as per the 2011 sensors it needs replacement at an interval of three to five years. So that means the requirement is too high.


If I distribute the different types of disability, locomotor comes the highest percentage. It also includes multiple disabilities. Also input moment disability or geriatric cases. So locomotor almost it has been distributed as 19% and it will go up around 36 percent if we include all the disabled who need mobility. On the world stage, it is the same. It was estimated in 2003 that around two-quarters of the population requires a wheelchair, those who don’t have a single one. That means it’s huge device mobility by requirement. It is really huge throughout the world.


Commercial angle if I see in 2017-2018 it is around 16,141.4 million US dollar business volume in the world. So it is expected to grow up to 31 million US dollars in 2027. So business-wise also is a huge market of assistive technology and assistive devices.


There is international or national legislation in this regard to support the stake or rights of the person of disability. If you need the United Nations rule state, rule three specifies all the states and the country so they approve of this provision. We have some service that is essential in order to sustain their optimum level of independence and functioning. Article 25 recognizes the persons as the deciders to the evolution of their rights. Article 26 states of the country should insert the treatment or health-related you have the sun extend to the personal disability. Similarly, in our country, sections 40, 41, and 42 of the RBW Act say access to all, means includes transport building information should be accessible or it should be barrier-free. It should be a mandatory provision in the accessible norms of CPWD or NIC or transport system because it’s completely extended broadly. We call immersion or inclusivity of all similarly, who is a World Health Organization, they also the same, it might be an attempt to do the same thing. 71.8 resolution, they prepared a draft on the book also the proposal focus on global action on assistive technology gaps even out of 195 countries in the world 60 countries participated in the seminar or you can see it the conference in Geneva where it has been united say decided the GATT or general agreement on assistive technology. So we implemented it throughout the world.


Something if I distribute the different devices we find around as for the delivery or you can say 20% of mobility aids and 16% of the daily living constitute around 36% it just comes under the locomotor disability. So it’s a major portion of the assistive technology assistive device, the purple.


Yeah, it starts with the child. So basically, we all know the teen disability it’s very tough. To walk right up to attend the schools. And it is very tough to follow the teaching bacteria because of the problem of the loss of limb or because of the paralysis or because of the weakness in case of locomotor disability. We don’t have the access to schools or colleges or you can say buildings for people with disabilities to access them.


Even though growth stays when the child grows, we learn how to stand we learn how to sit, we learn how to walk, that process, generally we all know that process happens automatically. We have a normal brain. But if you don’t have the input sensor or the input like Like what do we have input type sensor we have, if loss of any sensor, the entire process will be deformed or processes not complete. So that means we should have a very clear facility to go to have a normal motor development against the different challenges in case of high-level amputation.  this lady report to us with a bilateral accident. She lost both legs in a train accident. Initially, she is not able to stand. She is not able to maintain the center of gravity. Then subsequently with some rehabilitation, we make them stand, make them see then make them work, to make them run also sometimes. So there is a lot of series of the device which you need in between the different process that also comes under assistive technology. You can see from the picture, a lot of the conventional devices were very low-cost devices. What we provide to make the person adopting or you can say biomechanically adaptable to the last part of the limb so that the person can use the biomechanics, mechatronics or exoskeleton, or any high-tech device, what generally the technocrats are planning. So before that, a lot of devices were required to make the technology viable. Similarly, it’s not only the cases where we could see in the geriatric. it can be present in pediatric or from infancy they all need some sort of device. I hope that in the introductory section what Mr. Anil said we should have a demonstration or we should have the device-specific demonstration but isn’t it’s not possible. I’m sorry. So if you want to have another seminar I can go device by device but at a glance, you can see different types of prosthetics, ortho prosthetics also for which are mostly mechanical or passive in nature, but things which can be automated through a joint or mechanism which will come later on.


From bilateral or trilateral loss, sometimes quadrilateral support loss. They also need to rehabilitate their life they need to work and then it will do their daily activity for the household or for living. School child post-burn to simple amputation also need some sort of standing device or to adopt the post-burn or to release the contracts of the post-burn. Similarly for diabetics, for cancer, for noncommunicable disease or stroke, everywhere we find the use of assistive technology. So yeah, it may be a speech but it’s a fact that there are people many people who do not have assistive technology, assistive devices. Those are even medical faculty even in the treatment of the treating surgeons also, because life can be easy or life can be more adaptive, life can be easier to use the function or to use the device or use the interesting technology it gadgets or any sorts of a mechanical device for the day to day activity.


Starting from standing or running or from work, even you can sell simple devices we call them low tech or no tech, a person can’t even climb stairs, we can make a single sort of stair and then create a handle and then the person can take the handle and take the support. He can move with an investment of only 100 or 200 rupees. But if I say the person can’t reach the stairs, then the person will be disabled from the environment. So that means the barrier like washrooms, stairs, or buildings where you will find many of the disabled children are school children of officers, those who are also living with high society have no accessibility.


Yes, a lot of simple technology. It was published in Time magazine. A simple hydraulic operated handing device or walker is able to make the person walk, stand, sit so the person can rest in between during the walking process. Yeah, it is present in all airports mostly, this simple device can make a bilateral amputee, those who don’t have either of their hands or those who don’t have the normal hand can drink water. If they don’t have hands, how will they take the water? I’m just afraid of my time here. There are different devices that come under the locomotor. It will be a mobility device that is very, very populated or very dominating in achievements. I say locomotor disability and mobility device, many people have some concept. They’re sitting devices, they are bathroom devices, they are environmental control devices, there are ADL devices. ADL means to cook, to eat, to brush, to come to operate the entire spectrum of activity is called ADL. The prosthetic device overall, the loss part of the body, to replace the loss part of the body that physical loss, orthopedic part to support that weakened part of the body like paralyzed, like deformity, like cancer or like weak part and lastly the exoskeleton which is very common nowadays we’re coming up to the field which will make the person walk with the power device.


A recent advance which we are also working on, I’ll talk about that. The concept of mechanical wheelchairs that are inserted to power which I don’t have the time other than console video in my clinic. People find all mechanical wheelchair has been replaced by motorized wheelchair. Nowadays people claim and this is surprising to note, basically I’m a physician, it is surprising to note people demand motorized wheelchairs. If you tell them take a distorted wheelchair by the government of India, free of cost. No. They want to pay, they want better treatment, they want better mobility. So in our data, we found in 2015 the treatment free of cost was 90%, almost 90%. Now the payment has come to 60% of the total population. That means they also need good technology for a better life. So all wheelchairs will be replaced by power wheelchairs in the course of time, may not be all but the majority. Similarly, prosthetics are also replaced by mechatronics or orthosis will be replaced by functional electrical stimulation for neural processes. Similarly, robotics will come up. I hope the students, those research scholars coding similarly for exercise purposes per person to physiotherapy per person to in between treatment after accidents. Before going to bed or before going to the office, environmental control a person where he or she will go back to the home on how you operate TV how you operate, inter gadgets. Bionics is also coming in a very big way.


So this is a conventional wheelchair. What we are talking about is a mechanical wheelchair, or tricycle because this wheelchair is for going outside. Generally, the people known in our doctor group are called twice a year, but she’s still in a wheelchair for outside. All are mechanical.I hope all the students or maybe the department will have this, but okay.


Yeah. Similarly, the prosthetics. This is a cytoskeletal prosthesis, this is an exoskeleton prosthesis. These are highly adjustable prostheses. And these are very conventional prostheses, which only cost about 4000 rupees. All for cosmetic purposes, nonfunctional. A few functions are present. The kids are controlling it will close it will move by if you pull a cable through body power So, almost this is also conventional and replaced by minority processes.


For example, I saw due to heavy body weight due to the ligament injury, the person needs to get orthosis for walking purposes. Similarly for hands, similarly leg, or similarly for spine due to different types of anomalies. And that’s one interesting point, I don’t know why but most of the orthosis comes from the name of cities. Milwaukee-based, Boston-based all from the top developed country cities. So basically the device’s design or you can say the clinical trial is based in that city by a few professionals. So here I am sure the kind of talent the kind of facility we have if we collaborate, we can do the same thing but other western country people are doing and the topic of interest, I hope people are working on this. Basically, we call our device assistive technology because if I divide the conventional on what has already been discussed or presented, advanced ones come to the control system Mechatronics, electronics, IT or computer system, intelligent algorithms. So that’s where we got interested, starting from pacemaker to artificial skin, everybody we all are interested in that. So if I got a simple knee joint, simple and easy or simple elbow joint, simple wrist joint, this can be activated through Mechatronics control.


Yeah, an example is a feeding robot. People say they’re about to allow another person to take the food properly. Similarly for low knee, this is a mechatronics process where the process needs the command near the information of a process that means the future is depending on or depends on a qualified or licensed prosthetic. How to make the guidance, how to make the speech or how to activate, or whatever the incidence of evidence control. But if you make it purely robotic, or robot automatically senses for the different sensor we all know different sensors and actuate the actuator depending on the requirement of the person or speed of the working or different guidance, so the number of knee joints even, in fact, I’m also working on this with ISRO, the end of the knee joint it ranges from cost of rupees 50,000 to 16 lakhs. So the most commercially available auto knee joint cost around 10 lakhs or 22 lakhs or maybe is up to 44 lakhs. So, it is not possible for Indians or us people to afford it. But honestly saying the technology cost is high because of the research because of the algorithm because of the knowledge. If you go to the electronics part is a very simple block diagram but anyway is not easy. There are 6000 components and a lot of series of programs and that needs a different system in particular Mechatronics knee joint. Similarly, hand gloves to operate a mouse or to operate the keyboard or to operate differently depending on the residual movement. If I have this movement, I will program this. If I have this moment I will program this. if a person is not completely paralyzed, if a person has partial paralysis, she or he should not be discarded. Not able to walk or not be able to operate a computer by using computer-assisted technology. Similarly, there are a lot of advanced orthodox which we called exoskeleton all robotic orthosis which will make the person walk in case of post-traumatic accident or post-traumatic paralysis


Similarly wheelchair, yeah, I hope IIT Chennai is also working on that. Basically, people knew wheelchairs which will work on even terrain because rural areas are the major problem where the majority of the populations are there. The kind of wheelchair that we have the motorized wheelchair, that can only work on a plane surface or inclined surface. It’s not fit for uneven terrain.


Microprocessor control ankle joint, we made an attempt through a DST project to actuate the ankle joint and to see how much benefit or how much physiological cost we got improved through a calibrated measurement. In this experiment, we found almost you can say the cost of the physiological cost of the working reduced by 60% in compared to the conventional processes. So that means a person can do more efficiently 60% better in compared to the normal mechanical passive processes. This device was patented and it’s not commercialized, but still the cost we kept was only 10,000. It’s visible or not, it’s not decided, but still within the cost of 50,000, the joint can be manufactured. But if I go to the commercial side, the cost is more than two lakhs. So yeah, these are commercially available ankle joint. We are short on time so I’ll conclude my session and go for questions. Thank you.


Anil: Thank you very much, Professor Lenka. We will now open the session to questions. I understand that Rita Amjad has a question. You can unmute yourself I hope and ask your question.


Rita: Good afternoon, sir. So yeah, I’m a student. I’m working with cases, the cases Spina Bifida. And it has meningioma to seal the patient….(voice fades)


Dr. Lenka: What is your question? Yes. Yeah, I got it. What is your question exactly? What do you want to ask? Yeah. Okay. You know, in Spina Bifida the case is neurological it involves the motor neurons. So, you should wait for the child to grow because if you go for amputation, then the paralytic portion or the sensory portion may go, so it should be decided later on. Exactly he should be given orthosis to start with a well-padded or well pressure distributed device. So that the baby will not get pressure also. Immediately she should be prescribed a standing device or walk device, not a wheelchair, it is very tough. The life will be again the baby will develop the contracts or like the tightness of the joints and baby will depend on the wheelchair throughout the life. And still honestly saying wheelchair is not accessible to the entire physical environment. So you should give orthosis with a well-padded, pressure-distributed sensory device. it’s not recommended for amputation, yes. What’s the age of the child?


Anil: It is 14


Dr. Lenka: Yeah, I was right. So may I know the detail if you can mail me the exact condition or the prescription? I’ll definitely guide you, sure.


Anil: Are there any other questions for Professor Lanka? I had one question. So what follows up from what Rita just asked you, see, how do people get in touch? How do they know something exists? How do they know that this expertise exists? And your institute in Calcutta? Is there a formal mechanism of any kind that we can think of where people can connect very easily and get such kind of advice without having to register for Empower and listen to your talk.


Dr. Lenka: Yeah, it’s a nice question. Even our ministry is expecting a big database you can say or the information system where simple Google searches are simple chatbox can give you answer. We can work on that. Like the facilities or different modalities. Automatically. It should be from the question-answer. The bot can decide or can link to the issue server facilities are available.


Anil: Yeah, something useful. Yeah. Okay. Well, thank you very much, Dr. Lenka. I’m sorry that we did not have more time. But it was very exciting to hear you talk about the work that is going on in your institution. And I always learn when I listened to you. So thank you very much. Thank you.


Our next speaker is Amrita and Amritha is at the Kerala State Institute of Design and their contributed paper is on the design development of care. SoI will stop talking and maybe Amritha can start. Before I would perhaps suggest that turn off your speaker and your microphone do the work.


Amritha: Am I audible now? Thank you so much. Thank you to EMPOWER for having us and giving us this opportunity to present our project title, adaptive chair for motor Design and Development of an adaptive chair for children with motor disabilities.


So we are a team of three I’m Amritha from Kerala State Institute of Design, Kollam, and Allu. Krishnan also is a part he’s also from KSID and Dr. Akila Surendran from NISH was our guide. And so let’s begin with how we started this project. There was a boy we call hi Ramu. He’s an eight-year-old boy enrolled for communication therapy in NISH. He usually sits on his mother’s lap during the therapy session and his mother at the time when he enrolled, was pregnant, so she was not able to carry him all the time. He so it’s it was very difficult for her to carry him and do the sessions. So from this problem, like how we can solve the problem, how we can keep him in a proper position and make the life of a mother a better.


So, for motor disabilities, these are classified into five categories. In the first level in this picture, you can see the child can carry himself like that is small. In the second level also. The fourth and fifth level is completely dependent on someone or a wheelchair he needs full support that person need full support and we are focusing on the fourth and fifth level. And these are the existing products on the online market.


You can see the first image shows we got this image from online and this cost around five to 6000 rupees and the second one is around 20,000 And the third image is from outside and international company and it’s cost around more than one lakh when it comes to India. So most of the designs are Indian design in the Indian market are very in very bad design or poor quality. And it’s not fit for everyone like if the child grows, it won’t be useful for the child for the future like after two-three or one years or two-three years. Children grow fast so it’s not easy for them to sit in the same chair like it’s not properly supported and of good quality. We can see the good quality ones are very expensive.


We had interviews and observations and met with experts, we went to Composite Regional Central, Calicut and DEIC- District Early Intervention Center, Kozhikode, and IMHANS – Institute of Mental Health and Neurosciences. And we met the physiotherapists, occupational therapists, and speech therapists there and we met around ten children and their parents that motor disabilities and some of them are having multiple disabilities and most of them are completely dependent upon their parents. They cannot do any work on their own.


This is the first girl we met. This is the chair just given from a government-organized government scheme. She’s 16 years old and this is this same chair designed for everyone they are taking the measurements but you can see in the first image that is not like it’s not supporting her at all her hips or her legs are coming out and she cannot keep her leg properly and there was an activity tray also which is because of her legs. She cannot keep her legs properly there and it hits on the activity trade and it was very painful for her and the edges are so sharp so sometimes she gets hurt. We don’t move her hand here and there. We don’t know how they’re moving. So it’s very easy to get hurt.


The second boy had this chair. He doesn’t like to sit in this at all because he’s not comfortable. You can see the position of the chair in the previous one. There was a small angle in this one that you can see that was straight 90 degrees. So sitting in he hesitated to sit he used to get Sheezus and he doesn’t want to sit in this at all. All the time. He wants to sit on his mother’s lap until it’s it makes the parents or caretakers very difficult for them to take care of the child the entire day. They have to give the entire attention. It’s just not easy for them as they have to go do some other work or household work. So it’s very difficult for them to take care of these babies.


Next, the existing problem we find out from which we have conducted around 10 case studies. We have met those children and what they have got from the government schemes. This is the first image you can see. This is also given by a government scheme and this boy is very fat and he is not able to sit in this chair at all. And you can see the angle there are no angle adjustments or the legs adjustment so it is difficult for him to sit in this one. He doesn’t use this chair that much from the beginning like when they gave it to them that time only they just used it and the second one is a normal wheelchair. This boy’s parents are a little bit financially better. So they bought a wheelchair for him to move for mobility taking him from one place to another like to go for the sessions and hospitals. From my research and case studies, I have found that each service passage will be charted one server policy then the motor disability. Each child is different, their needs are different.


Most of the chair makers, the adaptive chair makers in India are not considered the aesthetic part and comfortability of the client. They just made the chair like they just make they take the panels and cut it and paste it length give it to the people they are not even considering the like functionality or the angles or anything like that or the comfortability of the client and the adjustability factors or most of the chair you can see that it’s not there at all. And if the chairs are adjustable then the cost is very high which is not affordable for a low-income family. And the materials are sharp edges and it should be easy to clean and at least durable for five years. So it will be better for the parents if they invest in what one time it will be helpful for them. For a long time, it just will be easy for them. So our design brief was to create a seating system for children with motor disabilities that is customizable as per the requirements of the child and cost-effective.


So the process started from like ideation. We have created a random idea. We have generated random ideas like we just started from sketching like seating and different types of seating model adjustment. And from there, we next categorize these ideas into four parts. It’s called the COCD method. In this method, we divide the ideas in like, is it feasible or not feasible? And if it’s feasible and feasible, it’s in two categories. It’s very, very easy to make or if we need some more things. So non-feasible we can tinker in future we have some we need some more technologies to add. So these ideas are categorized into four. From there we will take the feasible ideas in we also combine two-three ideas and generate four ideas. I have taken the four ideas shown in the final ideas after COPD. These four ideas are then going through the SWOT analysis. In SWOT analysis we check the strength, weaknesses, opportunities, and threats of these, each and every idea. From there we select best we select the best idea that is this you can see the defined concept.


So, from that, we have taken the reviews and suggestions from the experts. We have made the small mock-ups of each final concept and we have considered and we have consulted these experts and we got some suggestions. So our final idea was to seating with some adjustments and with an activity tray so, from the experts, we got suggestions like that like there should be an angle like you can see in this picture you can see the seating and this is the 90 degree one and there is a tilt and the backrest you can tilt the angle, so 130-150 We have given the angle so it is easy for a child to lie down. And the fourth image is for the hips exercise. Strengthening hip exercise. So if we can see this angle the knee position is a little bit up. So it will strengthen your hips. And the seventh image you can see is for the knees so the force will come to your knees in this area you can see so these are the angle regiment adjustments we have to give for these children so it will be easy for them.


And they need partial head support and a trunk supporting belt that helps the child to sit in a proper position. So it should be easier for the child to stay in these adaptive chairs at least for two hours. So it should be easier for them to move easily and they need a strap underneath to keep the knee in one position and the site should feel safer. And these are the explorations of different mechanisms we have gone through for the activity tray and the head trunk support and neck support.


Next is some mock-up. One scale mock-up we have done in corrugated cardboard and you can see we have added the activity tray and the sister activity tree height adjustment and this is the seat adjustments. This is the neck support. And this is for the footrest.


We have taken this is to one scale mock-up to the experts again, then we got some suggestions that angle of the backrest should be adjusted like a little more tilt and seating should be like it can be movable form and height of the footrest should be adjusted and there should be straps and there should be a leg separator and activity trays. First, we design the activity tray when a rectangular shape and it should be in a more curvy shape so the child should feel safe.


This is an improved design. The final one with you can see that all the adjustments, backrest adjustments you can see the neck supporter and the trunk supporting belts and the leg separator is here and the footrest and this is the adjustments for the activity tray. This is a seat adjustment you can move the seat front and back


So Mood Board. We have chosen a very happy mood board. So most of the designs you have seen are very dull. So the people will feel that there is a taboo that okay, that child is very sick or just not well. So when you see your child sitting on our adapter chair, you should feel happy after seeing that, that others also feel happy. So we thought like we will consider the caretakers also second use secondary users also. And even the child also feels happy. And we have chosen very bright colors and we have the attributes to be happy, friendly, safe and carrying. These are the form explorations we have done for the side panels. The forms are very inspired by the characters, animal characters, and all the forms we chose, like the curvy one so it feels safe and not sharp, it’s a very safe and caring feeling.


So material exploration, we have chosen the materials which are available in the market like local market, so you have used plywood and these are the molds we have used and the upholstery we have soft upholstery so it is not sharp. It’s not heavy. Like it’s not hard. The child should feel very comfortable.


This is a mock-up collection we have made and this is a final one is to one. So final design and the different stages of prototyping. This is the final prototype we have made. So the seating is adjustable you can see the seating is adjustable and the backrest next approach and the trunk support side parents are all good safety edges covered with foam so the child won’t get hurt and the edges are given.


This is supported by a safety adjust and footrest you can see the belt there are these are and the bottle holder for the for their bottles. Working out the knobs we can adjust the height and height of the activity tray and this is the handle we can push the adapter chair and this is how the adjustments are done.


We have done short-term testing on two kids. So the suggestions we got from them, the parents or the structure are very heavy. And so we have to reduce the substructure and it’s not easy to pull because of the heaviness and it’s not easy to pull that one and support should be better and there should be a hip belt.


And long-term testing we have done in two months. This is a boy with whom we started this project and he did a better job. He started doing speech therapy very much like before he is not able to press this Big Mac. Now he started to press the button and call his mom. So the problem was he identified the problem was strong support. It was not a strong one to support him keeping him in place. And the angle adjustment he had some issues with the backrest.


So the future direction is for the different experts. We got some suggestions that we have to do more form exploration and size of the wheel because it’s a very small wheel we have useful use… So we have to use a bit bigger wheels and the placement of the wheel it’s it is far from me to that so it should be in a little bit nearby so it’s easy to move around and handle the placement of the handle. We kept the handle in the middle so it should be in a proper position to push it properly and the weight of the entire structure should be reduced and backrest of the angle as I said previously, it should be in one more angle, if it’s there it will be better and the strong supporting belt the knobs the materials of the knobs. It is good for the condition at Kerela but it won’t be good for some other place where the material can melt and melting can happen.


And the cover backrest there is the backside of this chair is not covered properly so it should be covered if the child is having a sibling, there is a chance the child will go inside this space. So thank you.


Anil: Thank you very much Amritha, that was very interesting. Talk on the development process of development. We have time for a quick question. We have our next speaker waiting so I’ll take one quick question if someone has


Attendee: Hello. Yeah, so I had a question. In cases of spina bifida will this chair work and what all modifications do we need? Because in spina bifida you have a lump coming out from the lower back region.


Amritha: Okay actually I didn’t get what is a spinal Bifida?


Attendee: It is a condition where the spinal cord is not well, it’s not inside the body is it a part of the spinal cord indeed. The lower back region which comes on like…


Amritha:  Okay, okay. So, this chair is basically a child structure. So we can be customized for anyone. So, if the person is having this difficulty, there should be support in the seating right? So some things should be kept inside like I don’t know exactly what we have, we have to research on that particular problem and identify what is better for that particular person. So we have to and which position or which material we have to place on keep that particular patient on. So are you getting what I’m saying?


Anil: Yeah, I think that’s actually so I guess, I think one of the main takeaways is that these chairs are not really a one size fit all and they have to be customized and so the platform that you develop has to be customizable so that the next person who comes in with another kind of impairment, and needs some modification, the caregivers in that geography can make that modification easily because the platform has been set up. We are a little more customizable than any standard wheelchair that is currently available or standard platform that is currently available in the market. That does summarize that. Yeah, very good. Thank you very much. Please do reach out to Amrita if you have further questions.


And I see Professor Riener has joined us. I’m very excited to have him on board. It was difficult. I know he was traveling and given the time difference it is currently morning before lunch for him at Zurich. Professor Riener has been working in biomechatronics for more than 20 years now. And he’s very popular for his Cyberthon. And we’ve heard many good things about the work that he does. And so without further ado, I will let Professor Riener speak to us.


Prof Riener: Thank you, Anil. I hope you can hear me well. Thanks for the invitation. And indeed I just made it to LUCA in Italy to give another talk in two hours. And now I’m happy to give this talk. I hope that technology works. I will also try to show some movies at my talk. So now I’m sharing my screen and starting the animation in order to speak about exoskeletons in rehabilitation. One of the main target groups in our work for people using exoskeletons is stroke patients. Stroke is a very common disease about 16 million cases are there worldwide every year and age is a risk factor. So the older people are at the highest risk to get a stroke and in many cases, the stroke leads to paralysis to hemiparesis will have the body is paralyzed. This requires treatment therapy physiotherapy occupational therapy. However, the patients are mostly most of the time are passive, because they cannot do all the time physiotherapy or occupational therapy. So about 90% of the time they’re lying in bed, they’re sleeping, they’re eating. They are talking to people they are watching television, which is also maybe important but not beneficial to the learning or relearning of movement of gait or our movements or grasping functions. We know that we need a higher intensity of training. And we know this, for example from children, when they start to move to walk before they walk already. They do up to 26,000 leg movements every day. So when they are lying supine, they are moving their legs like this all the time. And that of course forms their neural plasticity and the pattern they learn the movement but when they start to walk then they’re still doing 14,000 steps every day. That’s a high number we need to go shopping, talking or hiking to get to this number and with upper extremities that doing a lot of reach and grasp movement in the age of about 12 months, more than 2000 preacher grasp movers are done with the hands and the arms which further forms their capability to move. And still, it takes several years until they can do very secure movements. Consequently, we cannot expect that patients who suffer a stroke or any other kind of neurological disease, that the relearn movement after just months of physiotherapy done that say once a week or once a day. It’s much too little we need to get to higher intensities.


For this, we have several devices exoskeletons, for example, like the Lokomat which helped people to make this training intensity higher to do more training. And we can combine that kind of training with virtual reality with games to motivate the people, the patients, and in this way, also get a better outcome.


So there are different kinds of versions of these robots. There are robots that are exoskeletal devices like you see here, the local models just one out of a list of devices. Many of these devices are not commercially available, but they are available only in research labs. We also have some devices which are ineffective based where the foot or the ankle or the lower leg is connected to the end effector of a robotic machine in order to move the leg to produce a gait like both devices shows similar effects. However, the end effector-based approaches are a bit simpler, easier to mount but not so secure with the knee joint, the knee can hyperextend or move in a physiological way that needs some more personal efforts to control the knee joint movement. So there are several studies showing that that kind of training is indeed beneficial. So Mehrholz, for example, this Cochrane report 2017 where they found that the kind of device does not matter so much. That study was based on 36 randomized clinical trials involving almost 1500 patients. And what they found out is that it matters if the patients are sub-acute, acute, or chronic. And if the patients are ambulatory or not ambulatory, when they start to move and they find out especially if the patients are non-ambulatory so then that they usually need a wheelchair for example, for that patient that’s quite clear benefits of that kind of training.


Let’s go to the upper extremities also that we have excess girdle devices like the Amin, which I have developed in my lap in the last 18 years in Zurich. And we have other exascale devices whereas the Amin was the first exoskeletal rehabilitation device existing in our community in the world. But in the meantime, more devices are available, mainly research labs. And we also have effector-based robots like the MIT Manas. That’s an older device from the 90s very famous and successful to support therapy in, especially stroke patients. And there’s also another study from Yan Mia Holtz from three years ago, showing very beneficial effects that were based on 45 trials with more than 1600 participants or patients. And they showed that robot-assisted arm training improved activities of living scores and also on function and also on muscle strength and this quality of the evidence is very high.


So that was about some exoskeletal, which can be used for therapy for training. These are usually by key heavy devices because the patients are getting to the clinic in order to get this training in order to improve body function. Another big field in our research and development is the use of such kind of technology for daily assistance for this we need to have more lightweight systems, mobile wearable systems to get in support for the people in daily life. It can also include a therapeutic effect, but mostly I’m focusing now on an assistive effect. So it’s an exoskeleton that can be an assistive device, as well as a wheelchair can or crutches or hearing aids or anything else which assists people in daily life.


One device which is also on this borderline between therapy and assistance is that device and Darko from Hocoma for example, which allows us to also get make people more mobile it’s not an exoskeleton, but still, a device that can assist people in daily life and make by making them more mobile.


That’s another very famous exoskeletal device ReWalk comes from a famous company from Israel. And that’s a picture which was taken at the London Olympics nine years ago, where a person with him after a stroke. No, it was I think, a spinal cord injured patient was very successful in participating in a marathon. It took her however 60 days to complete that race, but she did produce a lot of media reactions because it was a great step at that time. Using such a technology. There are many more devices available in the market from Japan like Honda or Cyberdyne, but also from New Zealand. Rexbionics and the United States like Parker, or EksoBionics many more devices exist in research labs.


And most of these devices are bulky or rigid. That second has advantages because the devices can be made quite strong. And since the devices are rigid, the weights and the forces are transferred by the device and not the bones and joints of the patient. That’s a big advantage. However, there are also disadvantages. The devices are very bulky and heavy that can misalign at the joints which can lead to discomfort and the device can collide with the environment and damage the environment for example. So that’s why we focus on soft robots and soft exoskeletons on exosuits or extra muscles as we call them. Conor Walsh was one of the first to develop such a kind of exosuit as you see on the right side of this picture, and we developed a new device with a different target scenario. Our scenario was not so much for soldiers, for example is the one from Connor Walsh. He made a device which was mainly for walking fast. And we said we need to support gait at all to walk slowly to do some weight support. And for example, to allow people to use a wheelchair because the wheelchair is a great device. They’re affordable. They’re working well, they don’t need the people, they don’t need a lot of energy to propel us at ease even to ride. But sometimes when there’s a step, there’s a challenge because they need to maybe get up from a wheelchair and get into a bakery. And then they can enter the store. They can look at somebody at eye-to-eye level. They can take something out of a shelf and then walk back to the wheelchair and drive again. I think the perfect solution in the midterm and long run is a hybrid solution where we apply wheelchairs together with exoskeletons, but so that the exoskeleton must be small. It must be fit for the patient while they’re sitting in a wheelchair. And then we also don’t need too much energy because sometimes we need to use the exoskeleton.


So we started with a new design and we said let’s make it very simple at the beginning and lightweight. The simpler the more likely we can make it the less power we need. We try to use just one motor per leg so two motors overall, but still to actuate several trends. So we could apply a motor which produces talks at the knee joint at the hip joint and the ankle joint if you connect them somehow with some kind of fear technology or with cables. So we use the cable-based approach. And we said we asked ourselves how we can guide the cable around the hip joint and the knee joint to produce joint torques a joint synergy, moment synergy, which is useful for gait and for stair climbing and for standing up or sitting down. So if you have a cable, we can only produce tension torques or tension forces around the cable around the joint so we can only produce one joint extension to torque at a joint or one joint flexion torque or no torque. So we have three options per joint. And since we have three joints that are relevant, the hip, the knee, and the ankle joint, we can make three over three options. So three to the power of three gives us 27 possible solutions to produce only hip torque extension torque or hip and knee extension torque or hip and knee flexion torque and so on. We thought what is the most important gait physiology? What, where do we need what? Drink gait, during stair climbing and sitting, standing up or sitting down? And we found several useful phases of gait but the most promising one for us was the beginning of the stance phase, the first half maybe or 1/3 of the stance phase where we have the unloading phase or the loading phase. Here we need to produce anti-gravity talks especially at the knee joint at the hip joint in the middle curve. You see how we get a lot of high knee extension torque and high knee flexion torque, sorry it’s high hip extension torque and the high ankle torque as I try to use my cursor.


So let’s hear what I’m not mentioning. High hip extension torque and rather a high ankle torque a bit higher than the knee torque and the average. And that’s what we can stimulate or support by providing torque we have found it supporting the gluteus muscles which are extensor muscles for the hip joint and the Quadratus Femoris muscles which also extend muscles for the knee joint. And we can provide this but carry the cable this way the cable must go behind a posterior hip joint and anterior the knee joint. The ankle doesn’t need too much support. So here we do not need to provide the cable and the first solution looks like this. You see how the cable was guided at the ankle with just anchoring which has does not produce torque here. And then we have the table in front of the knee to produce extension talk when the table gets shorter. And here behind the hip joint to get an extension to torque the hip joint at the first one usually provided the motor at the foot or the lower leg to keep the back free so that the people can still sit in a wheelchair. But later we figured out that that’s not a problem with inertia, but with a weight to lift the leg. And that was not supporting so much it was of course a problem. And that’s why in the new version, we placed the motor at the back. Here are another few ways we provide that technology: how we made this we have three layers. There’s a garment layer as a deep layer right at the skin. Then we have a ligament layer here with passive ligaments to produce also a little bit of extension or flexion torques. Then we have the power layer with a table that produces the mentioned extension talks. That’s the first version of the device was a Ph.D. student Skye Schmidt who made this and that was the second version of the device. We could provide up to 400 Newton in the cable and that gave us about one search, almost one-half of the required maximum torques. But these torques were enough to support data of people with more severe paralysis.


That shows the basic principle actually, we use emos inertial measurement units to detect them, inclination angles of society, the trunk, and the lower leg. And as soon as that inclination is bigger, indicating that there’s too much flexion for example when the patient is falling due to gravity, joints are flexing and the IMU are recording this and then the motors are getting active and blocking it. You see he’s getting blocked he cannot fall further. That’s the basic idea. We support extension talks to avoid flexions to avoid falling to support gates when the loading response at the beginning of the gait phase and also support standing up or walking upstairs.


We did many kinds of testings for different kinds of movements as you see in the green part above. We did many kinds of recordings inside the machine. We have a lot of sensors at the beginning even for sensors and now it is kinetic kinematic sensors, it moves. We also left sensing by ground reaction forces by the motion tracking system. We measured metabolic costs in some studies, also cardiovascular responses, and let’s also fill out the patient questionnaires. And this we could validate this technology a lot. We’re also happy to found a company and startup from ETH MyoSwiss, and Skye Schmidt is now the CTO of that company. My former postdoc Jaime Duarte is the CEO of the company. That’s a later version of the device where we have placed the model radio the backpack and the anchor. It’s the device at the ankle joint.


And it’s another few you see here from the side with the cable which is activated from the tender motor unit here top and you see now walking off a patient with muscular dystrophy and on the left you see it switch off the device just in the transplant mode and the right-hand side it’s switched on which allows a much faster-walking speed.


That patient could even join the three-week marathon two years ago. Not fast, but he could walk about six kilometers just a part of the mountain of course, and normally he can just walk hundreds of meters so we can do it much longer and he’s using it at home privately he can put it on himself and put it off again and use it to take a walk with his wife. So you see here how easy it is to mount the system. It just takes a bit more than a minute or two minutes on the left. That’s experienced, supported to put it on to a patient or to help the subject the case on the right is this novice doing it the first time and both of them don’t need so much time to put it on.


And we even simplified the law the anchoring at the moment the newest version. As you see here. There’s no connection to the shoes required anymore.


Another left one will finish soon and the novice also finishes in a very good time. So this makes the acceptance very high of all sorts of the patients but also of people using it in therapy units in hospitals.


That shows the status of the tests till a year ago. More than 450 patients to test the device. It was sold to many different labs, mainly to labs or hospitals for therapy but also to in meantime to 15 patients who are using it privately as an assistive device for daily life and we have used it for patients with many different kinds of pathologies, not only muscle dystrophies but also spinal cord injury, MS, Parkinson’s on different kinds of features after stroke and traumatic brain injuries and also patients with orthopedic impairments. And now we started a new collaboration with a charity in Berlin with the biggest heart clinic in the world with patients with heart failure, because heart failure can lead lead to dyspnea. So shortage of respiration of condition of endurance and fatigue and this leads to little training intensity to lessen this training. In this way. There’s deconditioning which is increasing this player and fatigue. So we try to get out of this Devil’s circle in order to allow training to improve the endurance of these patients and work against fatigue and that’s the study we started. It started with 10 subjects so far in a very first visibility study. And that worked very well already. And now we’re starting a clinical study these days or weeks to further get some more evidence.


So that’s the idea of the use of the device. It’s a clinical therapy device, but it’s also possible to use it for home use and for daily assistance. We also go to the upper extremities, the same principle we use cables one motor per limp to support, especially lifting the arm against gravity for patients with muscle weakness. And here we have to deal with another problem. The shoulder can get unstable. You see that the clavicle can turn out when we don’t take care that can harm the body it can be painful. And block the range of movement displayed. And you see that how we can look in a patient with muscle weakness of the upper extremity or on the shoulder.


And with a passive orthosis. We can work against this, we use a special boa mechanism to provide tension. It’s just passive, but the therapist can adjust to produce pressure onto the clavicle and avoid this kind of instability. And that is allowing already the passive structure allows already higher reaching movement of the upper extremity in this kind of patients. And we are combining that technology soon with an active part with a motor that is driving the cable to lift the arm to support the lifting. And that’s how the device looks at the moment. It’s a lap device. So it’s not that variable yet because everything is mounted in the box, but we know from the Myo suit the other device for the legs, that we’re able to mount it to make it smaller and mounted to a backpack.


Last but not least, I want to show you a terror challenge and guide you to the idea of the Cyberthon and I saw in my daily work that there are still many challenges in the development of assistive devices for daily life. The devices are not that accepted. For example, the control of the device, how should the motor know what the user wants to do? Motor intention detection is an issue and no battery power is an issue and also weight is an issue also the price is issue accessibility countries which are less wealthy I would say it’s also an issue and that’s always what we want to take into account in a big event called the Cybertron. The first one did take place in 2016. At that time, we even had teams from India joining with processes that made it even to the final race was very impressive. So technology does not always have to be expensive to be successful. And the tasks we are doing here are related to daily life. It’s a bit like the Paralympics, but not you’re not searching for the people who are the strongest and the fastest. We want to award those who are able to provide, who are able to do the activities of daily living with technology and we give an extra nod in the future for those devices who have economic and also economically affordable.


That was a team from Korea, joining a race, discipline exoskeletons. We have six disciplines also devices or races with powered or unpowered procedures like processes and procedures powered wheelchairs which are able to mount says climb stairs or bike race with complete spinal cord injured patients using electrical muscle stimulation in the brain-computer interface race where the pilots are driving avatars in a screen on a screen in a game we had a lot of media interest from all over the world’s newspapers, and also scientific journals. We did publish the events and also the technology presented by the different teams in different journals including Nature and Science. And we did also get a nice award, for example, BBC was there and it was the most striking picture of the year was one Cyberthon, there’s a stamp about the Cyberthon. We went to the Guinness World Records book 2018 and now in September, there was just a new issue of the Guinness World Records book 2022 where the Cybertron is again mentioned in that book. We got awards from Yahoo. We got the European Excellence Award, and the Oscar of education the Global Education Award in two categories. Even President Putin I’m not a fan of Putin, but nevertheless, he was also mentioning the cyber clan and he’s supporting the Russian teams. And thanks to Putin there will be a race also in two years in Russia in Moscow. There will be a small version of the Cyberthon taking place. So the next event did take place last year as a global edition. We are organizing the next one for 2024 again. I hope some teams from India will join and I will show you a short movie about this. But at the event which we had last year, which wasn’t high, which was offline for now. It was an online event but people were decentralized participating some in Zurich, some in Moscow, in Hong Kong, in Bangkok, in South Africa, and so on. So we had 51 teams of pilots from many different countries and we connected everything online. The races were recorded a day before but then we did show them and nobody did know the results but then they saw which pilot was the fastest one. It was still very exciting in the new format which we created. And with this movie now, on the next slide, I show you how that’s events take place. It’s just a one-minute movie.


[Movie Plays]


Thank you for your attention.


Anil: Thank you very much, Professor Riener. That was absolutely fantastic. It is always wonderful to see what technology can do to help people. Maybe the audience has a few questions and maybe we’ll take a few of them. Does anyone have any questions?


Attendee: So it was an amazing experience to learn many things from your product. So as we could see, the exoskeletons were supported on the lower part of the back. So for those who are suffering from spinal complications, like scoliosis or Spina Bifida, what are the things which could be done as the reaction forces would be sent on the spine?


Prof Riener: Thank you for this question. If there are problems with a spine and the vertebra in the back with hinder, where the wearing of the backpack of the exoskeleton might be an exclusion criterion at the moment. For most patients we did include a large range of different pathologies, that was not a problem. But still, it’s not the most comfortable way to sit in a wheelchair or car seat, or any other seat. And I would be eager to somehow improve this to either place. The backpack is to a much higher level or to the front if possible. But then you have a problem if people are a bit more obese, that doesn’t work that well. So it’s a challenge to mount the backpack or to mount the drive and the computer at the right place. of the body.


Attendee: Thank you, sir. So we are actually currently designing an exoskeleton for people with spinal complications, actually for the final thesis. So we would love to get your valuable inputs and insights. Would it be possible to contact you, sir?


Prof Riener: Sure. Feel free to write me an email if you find the email publicly on the internet.


Anil: I’m sure I’ll also be able to share it with them. But yeah, I think one of the joyous things about working in this field is that geography has no boundaries. So I mean, there are people across the world who suffer from similar ailments and you know at different stages of their life. And it’s always very rewarding to see how small engineering successes translate into improved quality of life for many such people. So yeah, absolutely. I think if we are able to facilitate through our interactions, more collaborative work between your labs and the labs in India, I think I would definitely encourage a lot more of that.


Prof Riener: Thank you, I’m very happy if there could be some collaborations we get, by the way, many students studying robotics at ETH Zurich from Indian IIT Institute’s and we are still searching for teams from India who are working on Cyberthon races, who bring any kind of technology which you might already have, it can be prosthetics and wheelchairs. If they power the wheelchairs, but the procedures can be passive.


And you don’t even have to travel even you can do it remotely in your country in your city and create an online connection so that we can broadcast it to the next Cybertron 2024 or to one of the series which will take place. Please contact me or the head of the Cybertron office.


Anil: Definitely Are there any other questions? I see there’s an extension of the questions. If not, let’s thank Professor Riener again. We will use the sign of thanking Thank you.


Prof Riener: You’re welcome. Thank you for inviting me. Thank you very much. Okay.

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