Tremor is defined as a rhythmic, involuntary oscillatory movement of a body part. Although everyone exhibits a certain degree of tremor, some pathologies lead to very disabling tremors. These pathological tremors constitute the most prevalent movement disorder, and they imply severe difficulties in performing activities of daily living. Although tremors are currently managed through pharmacotherapy or surgery, these treatments present significant associated drawbacks: drugs often induce side effects and show decreased effectiveness over years of use, while surgery is a hazardous procedure for a very low percentage of eligible patients. In this context, recent research demonstrated the feasibility of managing upper limb tremors through wearable technologies that suppress tremors by modifying limb biomechanics or applying counteracting forces. Furthermore, recent experiments with transcutaneous afferent stimulation showed significant tremor attenuation. In this regard, this article reviews the devices developed following these tremor management paradigms, such as robotic exoskeletons, soft robotic exoskeletons, and transcutaneous neurostimulators. These works are presented, and their effectiveness is discussed. The article also evaluates the different metrics used for the validation of these devices and the lack of a standard validation procedure that allows the comparison among them.

Background: Hemiparetic gait is characterized by strong asymmetries that can severely affect the quality of life of stroke survivors. This type of asymmetry is due to motor deficits in the paretic leg and the resulting compensations in the nonparetic limb. In this study, we aimed to evaluate the effect of actively promoting gait symmetry in hemiparetic patients by assessing the behavior of both paretic and nonparetic lower limbs. This paper introduces the design and validation of the REFLEX prototype, a unilateral active knee–ankle–foot orthosis designed and developed to naturally assist the paretic limbs of hemiparetic patients during gait.Methods: REFLEX uses an adaptive frequency oscillator to estimate the continuous gait phase of the nonparetic limb. Based on this estimation, the device synchronically assists the paretic leg following two different control strategies: (1) replicating the movement of the nonparetic leg or (2) inducing a healthy gait pattern for the paretic leg. Technical validation of the system was implemented on three healthy subjects, while the effect of the generated assistance was assessed in three stroke patients. The effects of this assistance were evaluated in terms of interlimb symmetry with respect to spatiotemporal gait parameters such as step length or time, as well as the similarity between the joint’s motion in both legs.Results: Preliminary results proved the feasibility of the REFLEX prototype to assist gait by reinforcing symmetry. They also pointed out that the assistance of the paretic leg resulted in a decrease in the compensatory strategies developed by the nonparetic limb to achieve a functional gait. Notably, better results were attained when the assistance was provided according to a standard healthy pattern, which initially might suppose a lower symmetry but enabled a healthier evolution of the motion of the nonparetic limb.Conclusions: This work presents the preliminary validation of the REFLEX prototype, a unilateral knee exoskeleton for gait assistance in hemiparetic patients. The experimental results indicate that assisting the paretic leg of a hemiparetic patient based on the movement of their nonparetic leg is a valuable strategy for reducing the compensatory mechanisms developed by the nonparetic limb.

Inertial sensors have gained relevance as wearable sensors to acquire the kinematics of human limbs through fusion sensor algorithms and biomechanical models. However, there are some limitations to the use of Inertial Measurement Units in the control of wearable robotic devices: 1) Some approaches use magnetometer readings to estimate the orientation of the sensor, and, as a result, they are prone to errors due to electromagnetic interferences; 2) Biomechanical model-based approaches require complex and time-consuming calibration procedures. In order to address these issues, this paper proposes an Extended Kalman Filter to estimate sagittal lower limb kinematics during gait, based on gyroscopes and accelerometers and without requiring any calibration or sensor alignment process. As magnetometer measurements are not involved, this method is not affected by electromagnetic disturbances. Our approach calculates the knee rotation axis in real-time, and it estimates hip and ankle sagittal axes considering that the movements in that plane occur around parallel axes. We carried out an experimental validation with eight healthy subjects walking on a treadmill at different velocities. We obtained waveform RMS errors about 3.8°, 3.6°, and 4.8° for hip, knee, and ankle in the sagittal plane. We also assessed the performance of this method as a tool for controlling lower-limb robotic exoskeletons by detecting gait events or estimating the phase and frequency of the gait in real-time through an Adaptive Frequency Oscillator. The average RMS delay in the detection of gait events was lower than 60 ms, and the RMSE in the estimation of the gait phase was about 3% of the gait cycle. We conclude that the described method could be used as a controller for wearable robotic devices.

The limits of space travel are continuously evolving, and this creates increasingly extreme challenges for the crew’s health that must be addressed by the scientific community. Long-term exposure to micro-gravity, during orbital flights, contributes to muscle strength degradation and increases bone density loss. In recent years, several exercise devices have been developed to counteract the negative health effects of zero-gravity on astronauts. However, the relatively large size of these devices, the need for a dedicated space and the exercise time-frame for each astronaut, does not make these devices the best choice for future long range exploration missions. This paper presents a quasi-passive exosuit to provide muscle training using a small, portable, proprioceptive device. The exosuit promotes continuous exercise, by resisting the user’s motion, during routine all-day activity. This study assesses the effectiveness of the resistive exosuit by evaluating its effects on muscular endurance during a terrestrial walking task. The experimental assessment on biceps femoris and vastus lateralis, shows a mean increase in muscular activation of about $97.8\%$ during five repetitions of 3 min walking task at 3 km/h. The power frequency analysis shows an increase in muscular fatigue with a reduction of EMG median frequency of about $15.4\%$ for the studied muscles.

Essential tremor (ET) is a major cause of disability and is not effectively managed in half of the patients. We investigated whether mechanical vibration could reduce tremor in ET by selectively recruiting afferent pathways. We used piezoelectric actuators to deliver vibratory stimuli to the hand and forearm during long trials (4 min), while we monitored the tremor using inertial sensors. We analyzed the effect of four stimulation strategies, including different constant and variable vibration frequencies, in 18 ET patients. Although there was not a clear homogeneous response to vibration across patients and strategies, in most cases (50–72%) mechanical vibration was associated with an increase in the amplitude of their tremor. In contrast, the tremor was reduced in 5–22% of the patients, depending on the strategy. However, these results are hard to interpret given the intrinsic variability of the tremor: during equally long trials without vibration, the tremor changed significantly in 67% of the patients (increased in 45%; decreased in 22%). We conclude that mechanical vibration of the limb does not have a systematic effect on tremor in ET. Moreover, the observed intrinsic variability of the tremor should be taken into account when designing future experiments to assess tremor in ET and how it responds to any intervention.

Hemiparetic gait is the most common motor-disorder after stroke and, in spite of rehabilitation efforts, it is persistent in 50% of community dwelling stroke-survivors. Robotic exoskeletons have been proposed as assistive devices to support impaired joints. An example of these devices is the REFLEX knee exoskeleton, which assists the gait of hemiparetic subjects and whose action seems to be properly embodied by stroke survivors, who were able to adapt the motion of their non-assisted limbs and, therefore, reduce their compensation mechanisms. This paper presents an experimental validation carried out to deepen into the effects of REFLEX’s assistance in hemiparetic subjects. Special attention was paid to the effect produced in the muscular activity as a metric to evaluate the embodiment of this technology. Significant differences were obtained at the subject level due to the assistance; however, the high dispersion of the measured outcomes avoided extracting global effects at the group level. These results highlight the need of individually tailoring the action of the robot to the individual needs of each patient to maximize the beneficial outcomes. Extra research effort should be done to elucidate the neural mechanisms involved in the embodiment of external devices by stroke survivors.