Mechatronic Exoskeletons for Lower-Limb

Rehabilitation: An Innovative Review

Deyby Huamanchahua
School of Engineering and Sciences
Tecnologico de Monterrey
Monterrey, N.L., México
a00816108@itesm.mx
Yerson Taza-Aquino
Department of Mechatronics Engineering
Universidad Continental
Huancayo, Perú
74239368@continental.edu.pe
Jhon Figueroa-Bados
Department of Mechatronics Engineering
Universidad Continental
Huancayo, Perú
71873208@continental.edu.pe

Jason Alanya-Villanueva Adriana Vargas-Martinez Ricardo A. Ramirez-Mendoza

Mechatronic Engineering School of Engineering and Sciences School of Engineering and Sciences
Universidad Continental Tecnologico de Monterrey Tecnologico de Monterrey
Huancayo, Perú Monterrey, N.L., México Monterrey, N.L., México
73492658@continental.edu.pe adriana.vargas.mtz@tec.mx ricardo.ramirez@tec.mx

Abstract— Studies on the development of lower-limb
exoskeletons began in the 1960s. However, these robotic devices’
technological progress has been plodding, despite being studied
for a long time. Therefore, the purpose of this article is to
document a systematic review of the trends in the application of
components that are part of the development of exoskeletons
applied to the rehabilitation of lower-limbs. The objective is to
provide the researcher with a structured matrix that integrates
these components related to lower-limb exoskeletons
development. As methods, it used different databases and
specialized search engines that helped collect research from 2016
to 2020. The process of filtering and selecting the reviewed
research was carried out, leaving 90 selected. Finally, it is
concluded that there is still room for improvement and continue
development of lower-limb exoskeletons that contribute to the
rehabilitation process and are closer to the human lower-limb's
real functioning.
Keywords— exoskeleton, lower-limbs, rehabilitation, TRL
I. INTRODUCTION
Robotics is in development and growth; in recent years
robotic structures such as exoskeletons are being created and
manufactured to contribute and help human limbs in different
tasks. Exoskeletons are mechanical structures attached to the
human limbs to amplify or increase the user’s strength. The
main applications are in industries, military technology, and
medicine. The exoskeleton can be applied to perform
rehabilitation therapies for the upper and lower-limbs due to
some type of disease or accident that produces a temporary
loss of muscle activity [1].
The history of the development of exoskeletons began in
the 60s with the name of Man Amplifier created by Neil
Mizen; in 1965 the Hardiman Suit project led by General
Electric in the United States was carried out; this Motorized
exoskeleton was used to manipulate materials [2]. In 1980
Jeffrey Moore stated that the exoskeleton can help increase
human performance for military purposes [3].
The lower-limb exoskeletons began to develop in the
1960s; the reasons for their development were muscle
weakness. This robotic mechanism helped patients with spinal
cord injury to regain their gait. Rehabilitation technologies for
people with locomotion disabilities have been developed over
the years in several institutions and universities around the
world. Nowadays, there are different robotic devices that
provide autonomy to people with walking difficulties, among
which is the exoskeleton for lower-limbs.
People with some type of disability face common problems
that are reflected in the deterioration of their quality of life,
since in most cases they must depend economically and
socially on someone for their integration into society.
According to the World report on disability, in the year 2019,
it is estimated that more than one billion people live with some
type of disability, or about 15% of the world's population.
The main reasons for the disabilities can be divided into
two groups: muscular diseases and diseases that affect the
nervous system; in both cases, a treatment that favors the
recovery of the affected parts must be chosen. It is crucial to
perform rehabilitation therapy when you suffer from a
temporary loss of the upper and lower-limbs. Research trends
show that failure to perform good rehabilitation therapy results
in the ultimate loss of limbs. Based on the literature,
exoskeletons are being developed primarily for military,
industrial, and medical purposes.
This article’s objective is to systematically review the
development and creation trends of lower-limb exoskeletons
applied for rehabilitation where analysis of the characteristics
that compose them such as type of loss, supported movements,
degrees of freedom, material, actuators, and developmental
stage of the exoskeleton. Finally, conclusions will be made
based on recent trends shown by exoskeletons.
II. METHODOLOGY
For the development of this research, a search query was
made in the database of “Scopus”, “IEEE Explore”, “Springer
link”, “PubMed”, “Google Scholar”, also access articles from
journals such as “Redalyc”, “Science” as well as collaboration
and dissemination platforms such as “ResearchGate” and
“Dialnet”. Keywords were used such as an exoskeleton, lower-
limbs, and control. Eight hundred eighty results were obtained

978-1-6654-4067-7 / 21 / $ 31.00 © 2021 IEEE

and publications on lower-limb exoskeleton, movement
control, dynamic and kinematic analysis were excluded. This
process resulted in an average of 90 publications that covered
from 2016 to 2020.
III. REVIEW OF PUBLICATIONS
To simplify and structure the information. The lower-limb
exoskeletons were classified according to the sensors
implemented, degrees of freedom (DoF), type of loss of the
lower-limbs, supported limbs of the exoskeleton, material used
for manufacturing, actuators, and state of development of the
exoskeleton [prototype or study].
The review describes the different designs of the
mechanical and control parts of the lower-limb exoskeletons.
Also, interface connection components connect the actuators
with the human body.

TABLE I. EXOSKELETONS FOR REHABILITATION OF LOWER-LIMB

Reference Kind of Supported movements Degrees of freedom Material Actuators TRL
loss (DoF)
Pais, C [4] PMI CRT NE Aluminum AL 7
Lei, Z [5] PMI CR 4 Aluminum AL 5
Ann, K [6] PMI R 1 Carbon fiber NE 4
Tang, C [7] PMI CR 4 Aluminum AL 5
Hernández, J [8] LME CR 4 Aluminum AL 5
Zhou, L [9] PMI CR 2 Aluminum Al 4
Tibaduiza, D [10] AC CR 2 Aluminum AL 5
Peralta, V [11] H CRT 6 Aluminum APP 4
Gudiño J [12] PMI CRT 6 Aluminum APP 5
Maldonado, I [13] PMI CRT 6 Nylon APP 5
Blanco, A [14] AC CRT 6 Aluminum NE 5
Luna, L [15] PMI CRT 6 Aluminum S 2
Mohammad, S [16] PMI CR 4 NE NE 3
Wang, H [17] PMI CR 4 NE NE 6
Wang, Y [18] PMI CR 4 NE AL 1
Baquero, K [19] AC CRT 6 Aluminum AL 5
Dunai, L [20] PMI CRT 6 Aluminum-PLA AL 5
Alburqueque, C [21] PMI C 1 Aluminum-PLA S 5
Zhang, X [22] PMI T 1 NE SH 4
Kazemi, J [23] PMI CRT 4 Aluminum AL 5
Elias, A [24] PMI R 3 Aluminum AL 5
García, I [25] PMI CRT 3 Aluminum S 5
Chen C [26] PMI CRT 14 NE AL 7
Siddique, N [27] DM R 2 Aluminum-Carbon Fiber AL 5
Dos Santos, W [28] PMI CRT 6 NE AL 1
Elias, D [29] PMI CRT 3 NE AL 1
Villena, G [30] PMI CRT 4 Aluminum AN 4
Chicoma, C [31] PMI CRT 8 NE AL-SH 2
Mineev, S [32] PMI CRT 4 NE AL 2
Zheng, T [33] P CR 4 Aluminum AL 7
Leal, A [34] PMI R NE NE AL 1
Yue, C [35] PMI CRT 6 Aluminum AL 5
Ruiming, L [36] PMI NE 6 NE NE 2
Long, Y [37] PMI CRT 14 Aluminum Ah-S-AL 7
Kawale, S [38] PMI CRT 12 NE AH 5
Tanyildizi, A [39] PMI R 2 NE NE 2
Menga, G [40] PMI CRT 6 Aluminum AL 4
Villa, A [41] PMI CR 4 Aluminum AL 5
Rajasekaran, V [42] PMI CRT 6 Aluminum Al 5
 Ling, F [43] PMI T 1 Aluminum S 5
Mayorca, D [44] PMI R 1 NE AL 4
Nunes, P [45] AC CRT 6 Aluminum NE 1
Munadi, M [46] AP CRT 6 Aluminum AL 6
Riesco, P [47] PMI CR 4 Aluminum S 5
Villarejo, J [48] PMI CR 4 NE NE 6
Torres, M [49] AP CR 4 Aluminum S 6
Arnago, G [50] PMI CRT 6 Aluminum APP 5
Lliguay, J [51] PMI CRT 6 Steel-Nylon NE 5
Davila, D [52] PMI CRT 6 Steel S 5
Alcivar, M [53] PMI CRT 6 PLA-Aluminum AL 5
Sánches, C [54] P CRT 6 Aluminum-Acer AL 6
Aya, P [55] AC CR 2 Aluminum-Steel AL 5
Garcés, A [56] P CRT 6 NE APP 6
Dos Santos, W [57] AC CRT 6 Aluminum AL 5
López, R [58] PMI RT 4 Polypropylene-Aluminum AE 4
Aguirre, E [59] PMI CRT 6 Aluminum S 6
Begue, J [60] PMI CRT 6 Aluminum-PLA AL 5
Tamburrino, B [61] ¨PMI CR 2 Aluminum-Steel AL 5
Mendoza, E [62] PMI CR 4 Aluminum S 5
Chamnikar, A [63] PMI CRT 3 NE NE 2
Romero, M [64] PMI CRT 6 Aluminum S 4
Long, Y [65] PMI CRT 10 Aluminum AH 5
Peñafiel, A [66] PMI CR 2 PLA Al 5
Marquez, H [67] PMI CRT 4 Aluminum AL 5
Mendoza, D [68] E CRT 3 NE NE 4
Ávila, E [69] P CR 2 Steel Al 5
Jim, D [70] PMI CRT 6 Aluminum AL 5
Majeeda, A [71] PMI CRT 3 NE NE 5
Núñez, K [72] H CRT 2 Aluminum S 5
Velandia, C [73] PMI RT 2 NE AL 4
Stopforth, R [74] PMI CRT 6 Aluminum AL 5
Hongchul, K [75] PMI CRT 6 Aluminum SH 5
Yi, L [76] PMI CRT 3 Aluminum Al 5
Byunghun, C [77] PMI CRT 6 NE AH-AL-AN 5
Belkadi, A [78] PMI R 2 NE AL 2
Pagre, A [79] PMI R 3 NE NE 2
Ajayi, M [80] PMI CR 7 NE AL 2
Yang, P [81] DM C 1 NE NE 1
Durandau, G [82] PMI CRT 6 NE AL 1
Trincado, F [83] PMI CRT 6 NE AL 2
Zakaria, A [84] PMI CRT 3 NE AL 1
Nasiri, N [85] PMI CRT 4 NE AL 2
Long, Y [86] PMI CR 2 Aluminum-Carbon Fiber AL 5
Aguilar, H [87] PMI CR 4 Aluminum AL 5
Velandia, C [88] PMI CRT 6 Aluminum AL 5
Rincon, K [89] PMI CRT 6 MDF S 4
Tovar, M [90] PMI CRT 14 PLA AL 6
Zhu, A [91] PMI CRT 6 Aluminum NE 5
Durandau, G [92] PMI CRT 6 NE Al 2
Wu, J [93] AC CRT 3 Aluminum AL 5
Note: Abbreviation: AC: Strokes, H: Hypertrophy, PMI: Loss of lower-limb movement, P: Paraplegia, LME: Spinal cord injury, E: Sclerosis, DM: Muscle deficiency, AP: Leg amputation, CR: hip and knee, CT:
Hip and ankle, RT: Knee and ankle, CRT: Hip, knee and ankle, R: Knee, C: Hip, T: Ankle, AL: Linear actuator, APP: Stepper Actuator, AN: Pneumatic Actuator, S: Servomotor, SH: Hydraulic Servo, AH:
 Hydraulic Actuator, AE: Elastic Actuator, TRL 1: Basic Research, TRL 2: Technology Formulation, TRL 3: Applied research, TRL 4: Small-scale development, TRL 5: Real-scale development, TRL 6: Valid
system in simulated environment, TRL 7: Real-environment validated system, N.E.: Unspecified

A. Type of loss developing prototypes of movements in RC [54,83], and a

Several types of loss were found in this group: loss of percentage of 7.8% indicates that exoskeletons are applied to
lower-limbs (PMI), muscular deficiency (DM), paraplegia (P), rehabilitate RT.
hypotrophy (H), cerebrovascular accidents (AC). Table II
describes the characteristics of the types of losses mentioned.

TABLE II. TYPES OF LOSSES

DM (Muscle
Loss of strength in the muscles
Deficiency)
Paraplegia reacts to the loss of control
of the trunk and generates a paralysis of
P (Paraplegia)
the muscles generating difficulty in
mobilizing and walking [94].

It is the decrease in muscle mass and

H (Hypotrophy) this implies the loss of strength,
generating the inability to stand.

It is a neurological pathology more

Fig. 1 Flexion / Extension, Abduction / Adduction and Internal / External
common in adults that generates severe
AC (Cerebrovascular Rotation movements. Source: K. L. Moore, A. F. Dalley, and A. M. Agur,
disabilities such as muscle weakness, Clinically Oriented Anatomy, Spain: Lippincott Williams & Wilkins, [2010]
accident)
loss of volumetric movements, and
causes difficulty in wandering [95].

The rest of the applications do not exceed 2.3% in Table IV, it

It is crucial to consider the type of loss that the patient is also observed that the most important supported movement is
suffered and to be able to develop an appropriate exoskeleton the knee since the mobility of the lower-limbs depends on that
to achieve rehabilitation since by not doing a good part of the body.
rehabilitation session it is very likely that the patient will lose
TABLE IV. PERCENTAGES OF STUDIES BASED ON SUPPORTED
the total mobility of their lower-limbs. As can be seen in Table MOVEMENTS
III, most of the studies were focused on PMI with 78.9%
[27,28,72], followed by AC with 7.8% [1,5,14] and the rest Supported Amount
movements Frequency Percentage
below 5%.
CRT 56 62,20%
TABLE III. PERCENTAGE OF STUDIES IN FACIÓN TO THE TYPE OF LOSS CR 21 23,30%
RT 9 10,00%
Muscle Amount C 2 2,20%
Deficiency Frequency Percentage
T 2 2,20%
PMI 71 78,90% Note:
CR: hip and knee, CT: Hip and ankle, RT: Knee and ankle, CRT:
AC 7 7,80% Hip, knee and ankle, R: Knee, C: Hip, T: Ankle
Q 4 4,40%
H 2 2,20%
DM 2 2,20% C. Degrees of Freedom (DoF)
AP 1 1,10%
In this area, a review is carried out on the degrees of
LME 1 1,10% freedom that exoskeleton prototypes have. The lower-limbs
Note: AC: Strokes, H: Hypertrophy, PMI: Loss of lower-limb
movement, P: Paraplegia, LME: Spinal cord injury, DM: Muscle have a total of 8 DoF at the hip has 3 DoF as shown in Fig. 2,
deficiency, AP: Leg amputation at the knee 2 DoF, and ankle 3 DoF as visualized in fig. 3 for
B. Supported movements each leg. It is considered ideal that a lower-limb exoskeleton
has the total DoF that the lower-limbs makeup, Table V shows
In this area, a review is carried out on the parts where that the highest number of exoskeletons with a percentage of
rehabilitation is applied through the lower-limbs’ exoskeletons. 38.2% have 6 DoF according to the reviewed research, with a
The lower-limbs count various movements are shown in Fig. 1; percentage of 21.3% have 4 DOF followed by 13.5% with 2
according to the reviewed research, applications were identified DoF. The exoskeletons that have 3 DoF, according to the
in the hip (C), ankle (T), knee-ankle (RT), hip-knee (CR), hip- research reviewed with a percentage of 11.2%, are devices
knee-ankle (CRT), and knee-ankle (RT). In Table IV the applied to a lower-limb. The image also shows exoskeletons
application that stands out the most in the studies are the with 1 DoF with a percentage of 6.7%; according to the
movements in CRT with 62.2% [33,37,45]. This reflects that research reviewed, these robotic devices consist of
the prototypes focus on performing a complete rehabilitation rehabilitating only a part of the lower-limb, be it ankle, knee, or
applying to the hip, knee, and ankle, which are the components hips. You can also find research on exoskeletons with 14 DoF
of a human lower-limb. Furthermore, 23.3% focused on
occupying a 3.4% percentage, closer to the DoF that human
limbs count.
Finally, with a percentage of 1.1%, investigations with 7 and 8
DoF were found according to the review carried out.
Fig. 2 Hip flexion increases by relaxing the hamstring muscles by flexing the
knee. Passively the bending is greater. Source: R.C. Miralles Marrero,
Clinical biomechanics of the locomotive system, Spain: MASSON, [2000]
robotic devices. 48.9% of the researches reviewed uses
aluminum material, taking advantage of the properties it
offers, unlike other materials, aluminum has a specific weight
of one-third of the weight of the metal, and aluminum has a
layer that protects it from rust; that is why most of the
researches reviewed use aluminum for the creation of their
prototypes [4]. As can be seen in the image for the
development of the mechanical structures of exoskeletons,
they combine other materials with PLA and aluminum with a
percentage of 4.4%, aluminum, and steel with a percentage of
3.3%, carbon fiber and aluminum with a percentage of 2.2%,
polypropylene, and aluminum with a percentage of 1.1%, steel
and nylon with a percentage of 1.1% according to the research
reviewed providing more versatility to your prototypes. The
figure also shows the use of PLA in a percentage of 2.2%, it is
a rarely used material, because the exoskeleton structure
usually supports loads greater than what the PLA material can
support, the use of steel is in the percentage 2.2% because this
material is very heavy compared to aluminum and this
generates muscle fatigue in patients when they undergo their
rehabilitation treatment. Finally, materials such as MDF and
nylon are rarely used for the development of exoskeletons due
to their mechanical composition that does not provide the
necessary support to support loads such as the weight of the
patient.

TABLE VI. PERCENTAGE OF THE TYPE OF MATERIAL USED FOR THE

DEVELOPMENT OF THE EXOSKELETAL STRUCTURE OF THE REVISED RESEARCH

Amount
Material
Frequency Percentage
Aluminum 44 48,90%
PLA-Aluminium 4 4,40%
Aluminium-Steel 3 3,30%
a) b) PLA 2 2,20%
Steel 2 2,20%
Fig. 3 (a) Representation and nomenclature of the six degrees of freedom of
Carbon-Aluminium Fiber 2 2,20%
movement of the knee: anterior and posterior translation, medial/side
translation and proximal/distal translation, flexion-extension rotation, internal- MDF 1 1,10%
external rotation and b) Representation and nomenclature of the six degrees of Nylon 1 1,10%
knee freedom of movement: anterior and posterior translation, medial/side Polypropylene-Aluminum 1 1,10%
translation and proximal/distal translation, bend-extension rotation, internal-
external rotation of varo-valgo. Source: M. Nordin and V. Frankel, BASIC Carbon Fiber 1 1,10%
BIOMECHANICS OF THE MUSCULOSKELETAL SYSTEM, Spain: Steel-Nylon 1 1,10%
McGRAW-HILL / INTERAMERICANA DE SPAIN, [2004]]. N.E. 28 31,10%

TABLE V. PERCENTAGE OF DOF OF LOWER-LIMB EXOSKELETONS

Degrees of Amount E. Actuators

freedom Frequency Percentage
The investigations developed solutions to imitating the
1 6 6,70%
movements with various actuators that do not affect the joints
2 12 13,50%
with sudden movements. Within these actuators, it was
3 10 11,20% possible to identify linear actuators (AL), step by step (APP),
4 19 21,30% hydraulic (AH), servomotors (S), and hydraulic servomotors
6 34 38,20% (SH). In Table 7 it can be observed that the linear actuator
7 1 1,10% stands out with a percentage of 54.4%, these actuators provide
8 1 1,10% a greater force to perform the movements [30-32]. It is also
12 1 1,10% possible to highlight the servomotors by restricting
14 3 3,40% movements to delimited positions as the programming
N.E. 2 2,20% indicates and the patient requires [22, 25, 34]. In Table VII the
stepper actuators are also shown with a percentage of 5.6%.
D. Type of material And finally, the other actuators that do not exceed 2.2% are
In this area, a review is made of the type of material they not as widely used for the development of these robotic
tend to use to develop the exoskeleton. Table VI shows the devices.
various materials that are used for the construction of these
 TABLE VII. PERCENTAGES OF STUDIES BASED ON THE ACTUATOR robotic devices are forecast to get closer and closer to ideal
EMPLOYED
performance in the future. It is hoped that this review will help
Actuator
Amount future projects and research to select the appropriate
Frequency Percentage components for the development of new prototypes.
AL 49 54,40%
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