Work 69 (2021) 775–793 775

DOI:10.3233/WOR-205012
IOS Press

Review Article

Lower limb rehabilitation robotics: The

current understanding and technology
Siddharth Bhardwaj, Abid Ali Khan∗ and Mohammad Muzammil
Department of Mechanical Engineering, Aligarh Muslim University, Aligarh, UP, India

Received 6 October 2020

Accepted 21 December 2020

Abstract.
BACKGROUND: With the increasing rate of ambulatory disabilities and rise in the elderly population, advance methods
to deliver the rehabilitation and assistive services to patients have become important. Lower limb robotic therapeutic and
assistive aids have been found to improve the rehabilitation outcome.
OBJECTIVE: The article aims to present the updated understanding in the field of lower limb rehabilitation robotics and
identify future research avenues.
METHODS: Groups of keywords relating to assistive technology, rehabilitation robotics, and lower limb were combined
and searched in EMBASE, IEEE Xplore Digital Library, Scopus, Web of Science and Google Scholar database.
RESULTS: Based on the literature collected from the databases we provide an overview of the understanding of robotics in
rehabilitation and state of the art devices for lower limb rehabilitation. Technological advancements in rehabilitation robotic
architecture (sensing, actuation and control) and biomechanical considerations in design have been discussed. Finally, a
discussion on the major advances, research directions, and challenges is presented.
CONCLUSIONS: Although the use of robotics has shown a promising approach to rehabilitation and reducing the burden
on caregivers, extensive and innovative research is still required in both cognitive and physical human-robot interaction to
achieve treatment efficacy and efficiency.

Keywords: Biomechatronic, rehabilitation robotics, assistive devices, lower limb, robot architecture.

1. Introduction wherein disability was most prevalent in the elderly

With the increase in life expectancy and the preva-
lence of chronic diseases, the disability rate is on the
rise. The latest available estimates of global disability
by World Health Organization (WHO) revealed that
there had been a marked increase in the number of
people with disabilities from 785 million persons in
2004 to 6.9 billion persons in 2010, of these around
110 million people were reported to be severely dis-
abled [1]. In the US alone, there had been an increase
in disability from 11.9% in 2010 to 12.8% in 2016,
∗ Address for correspondence: Abid Ali Khan, Department of
Mechanical Engineering, Aligarh Muslim University, Aligarh, UP,
India. Tel.: +91 9837111865; E-mail: abid.khan.me@amu.ac.in.
population [2]. Another report from United Nations
reveals that prominent population of the world is age-
ing, and by 2050 there will be two billion people
over 60 years of age which will account for 21.8%
of the total world population [3]. While the elderly
constitute the majority of the disabled population,
the working population (20–54 years) represents the
people with the greatest number of years lived with
disability mainly due to musculoskeletal and neuro-
logical disorders [4]. Hence, the health care system
is required to be flexible enough to meet the grow-
ing challenges in terms of the increasing number
of patients, more chronic diseases, rising cost and
skill shortages [5]. To meet this challenge, the health
care system is evolving by drawing advantages from
advances in information technology, engineering and

ISSN 1051-9815/$35.00 © 2021 – IOS Press. All rights reserved.

776 S. Bhardwaj et al. / Lower limb rehabilitation robotics
bioinformatics to provide an agile health system in
diagnosis, treatment and management.
Ambulatory disability is estimated to be the most
common type of disability with a prevalence of
6.5% ± 0.1% [2], wherein deformation in limb and
dysfunction in limb joints stands to be the promi-
nent factors contributing to the locomotor disability
[6]. Advancing age and diseases are responsible for
physical and functional losses. Various disorders have
been reported that contribute towards movement lim-
itations namely, musculoskeletal (e.g. osteoarthritis,
rheumatoid arthritis and back injuries), cardiovascu-
lar (e.g. coronary artery and peripheral heart disease),
pulmonary (e.g. chronic obstructive pulmonary dis-
ease) and neurological (stroke, cerebral palsy, spinal
cord injury and Parkinson’s disease) [7]. Further-
more, ambulation is found to be an utmost problem to
be addressed to cope up with other morbidities and
enable social and occupational reintegration of the
disabled [8].
Physical therapies and assistive aids form essential
elements of the preventive, restorative and mainte-
nance nature of the lower limb disability management
and rehabilitation. Physical therapies mainly include
exercise, training and compensatory strategies. Var-
ious convincing evidence is available that indicates
the usability of physical therapies in reducing and
delaying the progression of disabilities caused by
neurological and musculoskeletal disorders [9, 10].
On the other hand, assistive technologies are used to
increase, maintain or improve the functional capacity
of individuals, which in turn increases the indepen-
dence and participation of the user. [11]. Assistive
aids are further relevant for occupational workers to
reduce joint loading and promote wellness at work-
places by reducing the incidence of injuries and
work-related musculoskeletal disorders (WMSDs).
These assistive technologies range from a “low-tech”
velcro tape for shoe and clothing, walking cane,
etc., to a “high-tech” powered wheelchair for mobil-
ity, bionic prosthetics and orthotics, exoskeletons for
weight assistance, wearable sensors for physiological
monitoring, etc. [12, 13]. Assistive technologies have
also shown to reduce disability, thereby reducing the
need for support services and thus, the overall care
cost [1, 14].
The current research issues are mainly related to
the development of new therapeutic and assistive
modes that can help in improving the rehabilitation
outcome in terms of both shortening the treatment
durations, improving as well as assisting the activ-
ities of daily living. In this direction, robotics has
shown technological superiority in providing rehabil-
itation training and movement assistance. The current
article presents a narrative review covering the devel-
opments in rehabilitation robotics for lower limb
rehabilitation, focusing on their need, state of the art
designs, and their architecture in particular.
2. Literature search methodology
To obtain a collection of publications within the
scope of this narrative review, EMBASE, IEEE
Xplore Digital Library, Scopus, Web of Science and
Google Scholar database were searched for articles
published in the past 20 years (2000-2019) with
the combination of following keywords: lower-limb,
rehabilitation, robotics, exoskeleton, rehabilitation
robotics, assistance, therapy, leg, knee, training, mus-
culoskeletal, stroke, SCI, disability, human-robot,
biomechanics, gait, control. In addition, some arti-
cles published before the year 2000 are also referred
to present this review in a meaningful way. Out of
843 articles collected, titles and abstracts were scruti-
nized to exclude: articles peculiar to medicine but not
related to lower limb assistance including nutrition,
veterinary and surgery; articles relating to manu-
facturing science and prosthetics; articles related to
completely unrelated field including acoustics and
environmental science. After exclusion, 147 articles
(all published in English) were retained and classified
to bring out the developed understanding in the field
of lower limb rehabilitation robotics in recent years.
The articles were classified according to state of the
art the devices, designs, involved biomechanics, sen-
sors, actuators and control strategies.
We begin with a brief discussion on the need for a
paradigm shift from conventional methods to robotic
devices for rehabilitation (Section 3 and 4). We then
move on to reviewing the state of the art robotic
devices for lower limb rehabilitation (Section 5),
designing criterion (Section 6), biomechanical con-
siderations (Section 7) and their architecture (Section
8). Finally, we presented a discussion summarizing
the future perspective and challenges (Section 9) in
the domain of lower limb rehabilitation robotics.
3. Paradigm shift in rehabilitation
approaches
With the increase in disability rate as well as the
rise in the elderly population, there is a need for much
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
Fig. 1. Factors contributing to patient satisfaction in the rehabili-
tation process [16].
prompt and advance methods to deliver therapeutic
and assistive services. Also, with the growing patient-
centred approach, patient satisfaction has emerged to
be an important framework to access the quality of
healthcare services [15]. Patient satisfaction is also
linked to the rehabilitation perceived by the patient.
A satisfied patient is more likely to adhere to the treat-
ment, receive greater health benefit and have a higher
quality of life [16]. Figure 1 shows the factors that
contribute to a successful treatment (rehabilitation)
process and patient satisfaction.
This therapeutic alliance [17] is an important con-
tributor to patient rehabilitation. However, with the
growing health care demands and flexible needs, it is
evident that such therapeutic alliance cannot be met
by merely increasing the number of caregivers. The
challenge is aggravated by demographic changes,
growing chronic diseases, rising health care costs,
and skills shortages. To meet these objectives an inter-
disciplinary approach to the problem is sought. One
important element in this context is the introduction
of robotics in rehabilitation.
With the increasing interest of robotics in physi-
cal and occupational rehabilitation, much emphasis
is placed on assistive and training devices. On the
one hand, these systems could provide essential sup-
port for rehabilitation programs for both the therapist
and the patient, and on the other hand, they could
help older people or persons with reduced mobility in
their daily activities. These devices have been able to
overcome the shortcomings of traditional therapeu-
tic approaches and capabilities of the therapist and
caregivers, such as poor repeatability and struggle in
providing high intensity training protocols [18].
Apart from the ability of robotic devices to auto-
mate the treatment, these devices are also capable of
precisely quantifying the performance of the patient
during the exercise in terms of sensorimotor and
777
physiological variables. This has resulted in a shift
from a subjective evaluation of the treatment to a
more evidence-based, data driven, objective form of
treatment and assessment.
4. Rehabilitation robotics
Research on rehabilitation robotics began in the
late 1960s in the form of human-powered exoskele-
tons. Started with the objective of performance
augmentation primarily for military applications,
subsequent research has focused more on medical
exoskeletons for rehabilitation and assistive aids.
[19]. The later decade showed the development of
fixed base end-effector type robotic devices which
uses industrial manipulators until the development of
MIT-MANUS in 1989, which used planar manipula-
tors to reduce the mechanical output impedance [20].
Lokomat in 1994 marks the development of rehabil-
itation robots for lower extremity [21]. Since then,
the technology of rehabilitation robotics has grown
in terms of the architecture and application domain.
The field of lower limb rehabilitation robotics is
broadly comprised of therapeutic and assistive robots,
covering a range of different forms of post-traumatic,
post-operative and elderly health care services where
direct physical interaction with a robot system can
enhance the patient recovery or act as a replacement
for the lost functionality.
4.1. Therapeutic robots
Emphasis has been placed on the use of robotic
devices to achieve consistent and reproducible thera-
peutic movements. Since neuro-rehabilitation is both
time and labour intensive involving a large num-
ber of repetitive movement practices by the patient,
the application of rehabilitation robot can release
the therapist from heavy training tasks. Due to the
advantages of repeatability, accuracy and reliabil-
ity, therapy robots can provide an effective means of
improving rehabilitation outcome as well as reducing
health care costs [22].
Assessment of the human sensorimotor function
and retraining of the human brain are two key capa-
bilities of such devices in improving the patient’s
quality of life. The rehabilitation robotics fulfil these
functions by applying three types of therapeutic
techniques: priming, augmenting and task-specific
practices. Priming techniques include therap-
eutic interventions (e.g. passive movements, motor
778 S. Bhardwaj et al. / Lower limb rehabilitation robotics
imagery, etc.) that prepare sensorimotor system for
increased plasticity through direct stimulation of the
tissues or joints; augmenting techniques (e.g. EMG
biofeedback, constraint-induced movement therapy,
etc.) that emphasizes on improving the sensorimo-
tor interactions during the therapy; and task-spec-
ific practices which include the repetitive exercise/
movement to gain the plasticity and strength [23].
At present, much of the therapeutic robots are
focused on retraining the movement abilities of peo-
ple who have suffered a stroke or spinal cord injury.
The main reasons for this focus is the relatively large
number of patients with these conditions and the high
costs of rehabilitation associated with them. Section 5
provides details of various types of lower-limb reha-
bilitation robots which have been developed in recent
years to assist locomotor training to improve the gait
function and therefore patient independence.
4.2. Assistive robots
Body movement is one key area where assistive
devices have emerged to improve the activities of
daily living (ADL) in patients with SCI, neuromus-
cular disorders and ageing. Most of the researches
in assistive robotics are observed towards seamless
integration of assistive technology with the user. In
recent times, this integration has been improved by
developments in the mechanics of assistive devices
(both software and hardware), the physical interface
between technology and user, and intuitive control
strategies for device operation.
Robotic assistive devices are either used as “alter-
native devices” which are used in case of total inca-
pacity of mobility, or as “augmentative devices” for
patients with residual mobility capacity. Wheelchair
navigation systems support patients with a total
incapacity to mobility with an autonomous or semi-
autonomous mode of operation depending on the user
ability to manipulate the controls for steering and
obstacle avoidance. Wheelesley [24] and NavChair
[25] are two mostly explored smart wheelchairs for
their possibilities in providing mobility assistance.
Smart wheelchairs are augmented with IR sensors,
SONAR and machine vision to provide obstacle
avoidance and manoeuvring. Apart from joystick-
based control, bio-signals such as electromyography
(EMG), electroencephalography (EEG) and elec-
trooculography (EOG) has also been used to control
the wheelchair movement and steering [26, 27].
However, stagnant posture due to the continuous
use of a wheelchair poses a health problem to the
user in the form of bone loss, osteoporosis, muscle
atrophy, skin sores, etc. For these reasons, it is impor-
tant to encourage the use of augmentative devices
in place of alternative devices, whenever possible,
considering the mobility capacity of the user [28].
Augmentative devices for assistive aids include
external aids such as smart walkers and wearable
robots. Smart walkers have emerged as a robotic
alternative to conventional walkers, promoting bet-
ter assistance in gait and balance disorders. Guido is
an example of smart walker developed by Haptica
(Dublin, Ireland) that provide navigation and obsta-
cle avoidance assistance to frail, elderly, visually
impaired and Parkinson patients [29]. These smart
motorised walkers include sensorial setups such as
sonar, wheel encoders, laser, IR sensors and com-
puter vision for navigation and obstacle avoidance,
and force sensors and haptic feedback for steering.
Walkers have great potential for assistance; however,
smart walkers show lack of acceptance and adoption
by patients. Ergonomics and aesthetics of these walk-
ers need to be explored to improve and achieve total
acceptance [30].
Nowadays, the use of wearable robots, in the form
of exoskeletons or active orthosis, is rapidly increas-
ing toward lower limb assistive aids, where the robot
is designed to promote the functional activities at
home, society and workplace. The term ‘exoskele-
ton’ is generally referred to a device that augments
the performance of an able-bodied person, whereas
the term ‘orthosis’ is used for a device used to assist
a person with pathology or disability [31]. However,
there is no clear cut difference between orthosis and
exoskeleton, and the two terms for most of the part
are used interchangeably. In this article, the two terms
are used as they are referred in the associated ref-
erences.
Exoskeletons are used to actuate specific joints and
thus provide an assistive advantage to the user. Typ-
ical objectives of wearable robots are to establish
stable weight bearing, to control the speed or direc-
tion of limb motion, and to reduce the energy required
to ambulate. Tibion PK100 bionic leg (Tibion Bionic
Technologies, USA) is an example of partial lower
limb exoskeleton, which actively supplements the
knee movement for ambulatory assistance of patients
affected by neurological conditions. The device
includes a shoe with built-in force sensors to deter-
mine the user-required assist torque at the knee. The
device can be configured to operate in assist mode
(continuous assistance during the task), therapeutic
mode (providing assistance as needed by the patient)
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
or passive mode (for slow repetitive motion of the
knee) [32].
In many cases, it is difficult to have a clear cut dis-
tinction between the therapeutic and assistive robots,
as many devices offer the promise of combining both
the assistive and therapeutic technology together.
For example, ReWalk (ARGO Medical Technologies,
Germany), is not only an overground gait trainer for
patients with paraplegia but also facilitate them with
gait assistance to ambulate [33]. In the future, the dif-
ference between assistive and therapeutic aids will
mitigate. With the advancement in robotic exoskele-
tons, patients will be able to wear them in the home
and community, receiving both therapeutic interven-
tions and supportive assistance when needed. With
this viewpoint, it is essential to stress the research
and development of exoskeletons for the assistive and
therapeutic needs of the patient whenever possible.
5. State of the art robotic lower limb
rehabilitation devices
In recent years, various types of lower limb reha-
bilitation devices have been developed to enhance
the recovery and assist the motor function of the
patients. Figure 2 gives the categorical view of these
lower limb robots developed in recent years. In the
exoskeleton type of robots, there is one to one corre-
spondence with the human joint, while in end-effector
type robots the movement is generated by the most
distal segment with no one to one joint correspon-
dence.
5.1. Treadmill-based exoskeletons
In a treadmill-based exoskeleton (TBE), the patient
training is accompanied by the exoskeleton while
walking on the treadmill. They generally consist of
body weight support (BWS) system for ensuring
Fig. 2. Categories of lower limb rehabilitation robots.
779
safety, reducing the joint loading due to body weight
and maintaining balance [34]. Lokomat, LokoHelp,
AutoAmbulator and LOPES are clinically explored
treadmill-based rehabilitation robots.
Lokomat is an early TBE developed by Hocoma
(Zurich, Switzerland) consisting of cable BWS sys-
tem for gait rehabilitation. It consists of 2 degrees of
freedom (DOF) at each leg, assisting the hip and knee
movement in the sagittal plane. The joints are driven
by DC motors using ball screw transmission [21].
Woodway and LokoHelp group, Germany, developed
LokoHelp robot which was similar in construction
to Lokomat. The LokoHelp device is placed in the
middle of the treadmill, and the foot is tied to the
device to perform the simulated gait action [35].
AutoAmbulator developed by Healthsouth, US, is
another cable BWS system for gait training. It uses
robotic arms strapped to the ankle and thigh of the
patient to simulate the movement at the knee and
thigh. The use of robotic arm reduces the overall
weight of the device and ease donning and doffing
as compared to Lokomat [36]. LOPES (University of
Twente, Netherlands) is another TBE consisting of
8 DOF (two for pelvis translation and three revolute
joints at each leg) actuated through SEA [37].
5.2. Orthosis-based exoskeletons
Leg orthoses are actuated wearable lower limb
exoskeletons that can provide power assistance dur-
ing walking as well as act as overground gait trainers.
These are full and partial lower limb devices based
on the number of human joints assisted by the device.
Blaya and Herr [38] developed an Active Ankle–Foot
Orthosis (AAFO, Massachusetts Institute of Tech-
nology) for gait training of drop foot patients. In
AAFO, the impedance is modulated throughout the
gait cycle by biomimetic torsional spring control
using SEA. The variable impedance control at the
ankle joint was shown to reduce slap foot. In another
780 S. Bhardwaj et al. / Lower limb rehabilitation robotics
approach, pneumatic muscles were used for actuation
of knee and ankle joint in Knee-Ankle–Foot-Orthosis
(KAFO, University of Michigan) developed by Saw-
icki and Ferris [39]. The KAFO used proportional
myoelectric control with flexor inhibition algorithm
to reduce pneumatic muscles co-activation during the
simulated gait cycle.
The use of myoelectric signals is, however, diffi-
cult in case of neurologic patients due to weak EMG
signals. To cater this problem, Suzuki et al. [40] used
ground reaction force as another measure in Hybrid
Assistive Limb (HAL-5, Tsukuba University) to esti-
mate the user intent in full body exoskeleton for
assisting gait movement.
While the devices discussed above are used to
assist the user’s muscle, Berkley Lower Extremity
Exoskeleton (BLEEX) is a lower body exoskeleton
developed by Zoss et al. [41] to support external pay-
load mainly for military application. BLEEX consists
of 7 DOF consisting of hip, knee and ankle actuated
by hydraulics.
5.3. Foot plate-based end-effectors
In foot plate-based devices, patient’s feet are pos-
itioned on the preprogrammed foot plates to stimu-
late various walking phases. Unlike the exoskeleton
where the patient is fixed to the robot kinematics, pro-
viding no room for the therapist to physically access
the patient’s limb, the foot plate-based devices only
support the patient feet while the therapist physi-
cally accesses the patient’s limb during training. Gait
Trainer, GT-I (Reha-Stim, Germany), uses a plane-
tary gear system to drive the independent foot plates
to simulate the foot motion while the patient is sup-
ported by a cable BWS system. The device does
not constrain the patient’s knee, thereby allowing
the therapist to perform correction on the patient’s
movement [42].
A major redesign to GI-I is HapticWalker. Devel-
oped by Schmidt et al. [43], HapticWalker is a re-
programmable foot plate-based system with the
capability to simulate different terrain for comprehe-
nsive training of day to day activities such as walking
on a rough surface, stair climbing, etc. The system al-
so has a virtual reality (VR) mode, where the user
wears the VR display helmet and interact with the
virtual scene to augment the training [44]. To compe-
nsate for the larger size and high voltage requirement
of HapticWalker, Hesse et al. [45] developed G-EO-
System. The system was devised for maximum step
length of 0.55 m and gait velocity of 0.6 m/s.
5.4. Platform-based end-effectors
Platform-based devices allow the patient to be sta-
tionary while the affected limb is attached to the
platform, which in turn is controlled to execute the
training program. These include stationary gait train-
ers as in case of MotionMaker [46] and Lambda
[47], as well as stationary systems for ankle and
knee rehabilitation such as Rutgers ankle [48]
and High Performance Ankle Rehabilitation Robot
[49]. Parallel robots have become quite common
in platform-based rehabilitation devices. Compared
to exoskeleton-based devices, end-effector-based
robots can easily adapt to different patients. End-
effector robots typically make contact with the
patient’s body at specific points, making it easier to
design and control these types of robots [50].
6. Biomechatronics design criterion
The application of robotics in rehabilitation sce-
narios encompasses multiple aspects that need to be
carefully addressed. The user plays a crucial role in
robot-aided therapy since the early stage of the design
of such systems. Rehabilitation robot design must
meet user’s requirements; adapt to human perfor-
mance; and guarantee safety, robustness, reliability,
comfort and movement freedom while pursuing
the effectiveness of treatment or assistance. This
calls for a multidisciplinary approach to wearable
robot development, which is where the concept of
biomechatronics comes into play.
Bio-mechatronics may be regarded as an exten-
sion of mechatronics (Fig. 3). The scope of bio-mec-
hatronics is broader in three distinctive aspects:
firstly, bio-mechatronics intrinsically includes bio-
inspiration in the development of mechatronic
systems, e.g. the development of bioinspired mecha-
tronic components (control architectures, actuators,
Fig. 3. Biomechatronics design approach [51].
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
etc.) [52]; secondly, biomechatronics deals with
mechatronic systems in close interaction with biolog-
ical systems, e.g. cognitive and physical interaction
with the human; and thirdly, biomechatronics com-
monly adopts biologically inspired design and
optimization procedures in the development of
mechatronic systems, e.g. the adoption of genetic
algorithms and neural network in the optimization
of mechatronic components or systems [53].
A biomechatronic approach requires a detailed
characterization and modelling of the biological sys-
tem interacting with the robot before the classical,
mechatronic design cycle can be started. The key
aspect in the biomechatronic design process is the
in-depth analysis of human-activity interaction and
interfaces in the target application scenario to suitably
identify the subtasks and activities of interest for the
introduction of robotic technology in such scenario
[51].
6.1. Dual cognitive and physical interaction
The key distinctive aspect of wearable robots is
their intrinsic dual cognitive and physical interac-
tion with humans. In wearable robotics, a cognitive
human-robot interface (CHRI) is explicitly developed
to support the cognitive interaction (possibly two-
way) between the robot and the human. Information
is the result of processing, manipulating and orga-
nizing of data, and so the CHRI in the human-robot
direction is based on data acquired by a set of sensors
to measure bioelectrical and biomechanical variables.
Similarly, a physical human-robot interface (PHRI)
is explicitly developed to support the flow of power
between human and robot. The PHRI is based on a
set of actuators and a rigid structure that is used to
transmit forces to the human musculoskeletal system
[54]. The close physical interaction through this inter-
face imposes strict requirements on wearable robots
towards ergonomics, safety and dependability.
6.2. Neuromotor control
There are three levels of cognitive interactions:
one related to reasoning and planning, one related
to muscle activity and one related to the wearer’s
motion. The planning level interaction can be accom-
plished by monitoring brain activity using different
techniques, e.g. EEG or brain-implanted electrodes
[55]. The muscle activity level uses muscle electrical
activity, i.e. EMG, to command the devices [56]. The
movement-related level of interaction uses kinematic
781
and kinetic information from the subject as control
inputs [57]. Multimodal approaches propose diversi-
fied use of these channels to gather more realistic and
robust information and to gain a better understand-
ing of the phenomena through data fusion techniques
[58].
7. Biomechanical considerations
Since the robotic rehabilitation device work in par-
allel to human limb, it is crucial to understand the
biomechanics of the limb joints. The joint center
should be aligned with that of the limb and must
conform to the degree of freedom in the plane of
movement for allowing free, unrestricted movement.
7.1. Degree of freedom
The hip is considered to be ball and socket joint
with three degrees of rotations. The major design
challenge is posed in terms of abduction/adduction
and internal/external rotation at the hip joint. MIT
exoskeleton used cam mechanism to adapt for the
difference between biological and exoskeleton length
[59], while in BLEEX the researchers opted to posi-
tion the center of rotation for abduction/adduction
in the rear part of hip joint mechanism [41]. LOPES
also opted for a solution similar to BLEEX for provid-
ing abduction/adduction DOF [37]. Internal/external
rotation is provided in BLEEX by a single axis of
rotation in the middle of the hip joint at the rear
attachment [41].
The knee is condyloid joint with two degrees
of freedom (flexion/extension and internal/external
rotation) [60]. Despite this, for simplicity, the knee
joint is often modelled for flexion/extension due
to very limited longitudinal rotation. Most of the
knee exoskeleton considers single DOF at the knee
[61–64]. However, due to polycentric motion of the
knee in the sagittal plane [39], one purely rotatory
DOF is argued to cause misalignment thus over con-
straining the design and causing undesirable forces at
the point of attachment and knee [65]. Several designs
have been sought to achieve knee alignment. Kim et
al. [66] implemented a four bar linkage mechanism
to follow the polycentric motion of the knee. Liao et
al. [67] used a five bar linkage mechanism at the knee
to drive the shank part using a rack. Wang et al. [65]
used the rolling knee joint with a double hinge joint to
reduce the knee misalignment in the frontal and sagit-
tal plane. Celebi et al. [68] used Schmidt coupling,
782 S. Bhardwaj et al. / Lower limb rehabilitation robotics
which self-align with the translation of the instanta-
neous centre of rotation of the knee. In another design,
soft inflatable exosuit was designed by Sridar et al.
[69] to eliminate the misalignment and improve the
compliance between the device and knee movement.
The ankle is a complex joint having 3 rotational
DOF (internal/external rotation, plantar/dorsiflexion
and inversion/eversion). The use of all the 3 DOF
is advocated in design because the foot makes con-
tact with the ground [41]. However, to simplify the
mechanical design, the ankle is assumed to be hinge
joint having 1 DOF (plantar/dorsiflexion) as in the
case of ALEX (active leg exoskeleton) [70]. Multi
DOF at ankle joint has been realized for various
mechanical designs as in the case of ankle rehabil-
itation orthosis developed by Agrawal et al. [71] and
Zhang et al. [72].
7.2. Range of motion
Range of motion (ROM) requirement is dependent
on the application of the device and the driving mode.
Even though the exoskeleton bears anthropomorphic
design in most cases, the ROM didn’t need to be
same as the ROM of the biological limb. Zhang et
al. [73] reduced the range of motion at the hip, knee
and ankle to reduce the extra loading at the passive
hinges, reducing vibration and improving the safety
of the wearer. Singh et al. [74] replaced the hinge
joint at the knee with four bar linkage joint to obtain
a desired range of motion at the knee. Kubota and
Hasegawa [75] studied the physical feature of the
exoskeleton, which may interfere with the wearer’s
motion. ROM reportedly tends to reduce with the
thickness of exoskeleton if the medial part of the
thighs increases beyond 20 mm. ROM for exoskele-
tons designed for overground walking is generally
greater than the actual ROM of the limb to ensure
wearers safety and avoiding any restriction to the
movement [41].
7.3. Joint torque
To assist the wearer, a robotic device must provide
adequate movement torque either passively [37] or
actively [76]. Three methods are mostly used in deter-
mining the joint torque requirements- human body
modelling [77], clinical gait analysis [78, 79] and
experimental test using torque sensors [80]. Mostly,
the most significant joint torque is observed in the
sagittal plane, primarily in flexion/extension DOF
except for the hip joint where the greatest torque
is obtained in adduction/abduction. For this rea-
son, BLEEX, LOPES and MIT exoskeletons have
provided assistance at the hip to augment hip adduc-
tion/abduction [41, 81, 82]. The joint torque data is
essential in determining the actuation system required
at the joint of interest. The system must be able to
deliver the necessary motion velocity and adequate
frequency response for the dynamic task augmented
by the device [81]. The joint torque data is also used
to evaluate the muscular effort. Hwang and Jeon [80]
computed the active muscular effort from the mea-
sured torque at the knees.
8. Architecture of lower limb rehabilitation
robots
Three main aspects must be taken into account to
develop safe, efficient and portable robotic rehabilita-
tion devices: sensors, actuators and control strategy.
These are reviewed in the following sections.
8.1. Sensing
The sensors allow feedback from the device and
regulate the force, torque and position of the joint
necessary to perform the desired movement. Robotic
rehabilitation devices developed in the past have
used multiple sensors and their combinations such as
encoders, inertial measurement units (IMU), poten-
tiometers, sensors to measure bio-signals (EMG and
EEG), force and torque sensors, etc.
Ground contact force (GCF) is importantly mea-
sured in assistive devices to classify movement [83],
diagnosis of abnormal movement [84], model limb
[85] and for fall detection [86]. Force sensitive resis-
tors (FSR) and load cells are commonly used for the
measurement of ground force. Sahin et al. [87] devel-
oped hydraulically actuated exoskeleton which uses
FSR for measurement of ground reaction force while
load cells were used for the measurement of piston
force. The force measurements were used to drive
the exoskeleton using a proportional and integral (PI)
controller. In commercially developed exoskeleton
HAL, a semiconductor type floor reaction sensor was
used for GCF measurement for the movement control
[40]. Fiber-based force sensors have also been used
to improve comfort while walking [88].
Both active and passive range of motion (ROM)
measurements are employed in rehabilitation robots.
These measurements largely employ potentiometers
and encoders at the joints to measure joint angles
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
[89, 90]. However, these require to have their axis
aligned with the rotational axis of the joint. To over-
come the issue of misalignment in case of joints hav-
ing multi-axis rotation, inertial measurement units
(IMU) are used [91]. Strain gauge-based flexi-
ble goniometers [92] and optical-based goniometers
[93] are also tested for their usability in providing
multi-axial measurement and lightweight applica-
tion, however, they are fragile and not usable in daily
usage. A newer area is also being researched on the
use of teleceptive sensing (using stereo RGB cameras,
laser, radar, sonar, ultrasonic sensors) for wearable
assistive robotic devices [94].
Bio-signals have been incorporated in rehabili-
tation robotics with their potential to estimate the
human intent. Surface EMG electrodes have been
used for the measurement of myoelectric signals from
the superficial muscles for classification of movement
[95, 96] and to estimate joint torque [97, 98]. Fusion
of EMG with mechanical sensors such as IMU is
found useful in improving the classification accura-
cies [58]. Examples following the use of EEG signals
in exoskeletons are relatively few compared to EMG
due to the complicacies in EEG signal processing
and data mining. EEG-RoGO (Robotic Gait Orthosis)
[99] and BCI-MAFO (motorized ankle foot orthosis)
[100] are few EEG driven lower limb exoskeletons
developed for paraplegia patients. Mechanomyo-
graphic (MMG) signals, picked up from dermally
fixed accelerometer, were also used for the control
[101].
8.2. Actuation
Various actuation systems are being employed in
rehabilitation robotics in the past. These are classi-
fied as electric motor, pneumatic and hydraulic actua-
tors. Advantages and disadvantages of these actuation
drive systems have been documented by Zhang et
al. [44]. The actuation system must suffice in both
performance and physical aspect to comprehend the
workability of the exoskeleton. The performance req-
uirement includes high specific power, back-driva-
bility, ease of control and efficiency, while the key
physical requirements are low mass, low cost, mod-
ularity, and noise [102]. A comprehensive review of
actuators of various lower limb robotic rehabilitation
devices have been documented by Huo et al. [18].
Research has been shifted towards the use of com-
pliant actuators to improve the safety, efficiency and
comfort of the exoskeletons. Three types of compli-
ant actuation systems are commonly used – series
783
elastic actuators (SEA) [103, 104], variable stiffness
actuators (VSA) [105, 106] and pneumatic artifi-
cial muscles (PAM) [39, 107]. The use of SEA
in exoskeletons has demonstrated improved human-
robot interaction, and also aids in the measurement
of the joint torque based on the deformation of the
elastic element. Linear springs, torsional springs, spi-
ral springs, Bowden and steel cables have been used
as elastic element in SEA and VSA [108]. In VSA,
the stiffness of the elastic element can be modulated
to change the actuator characteristics thus adapting
to the environment and task [109]. The PAM has
the advantage of low weight, back-drivability and
high specific force [110]. Antagonist configurations
of PMA is also been used to obtain bidirectional actu-
ation [90]. However, these are particularly inefficient
in producing a large range of motion and high torque
due to non-linear force contraction behavior [111].
Both soft and rigid smart materials have found a
promising utility as actuators in robotic rehabilitation
devices. Shape memory alloy (SMA)-based artificial
muscles have been tested in ankle foot orthosis [112].
The use of SMA improves the tracking frequency of
PMA by 12 times and reduces the tracking error by
82%. Hyeon et al. [113] demonstrated the feasibility
of graphene/carbon nanotubes (CNT) yarn PMA in
robotic devices for actuation. The tensile actuation of
these electrochemical muscles was found to be twice
than coiled CNT muscle. Dielectric elastomer and
polymeric molecular actuators are also promising for
actuation of robotic rehabilitation devices because of
their stress, strain and speed similar to that of a human
muscle [102].
8.3. Control strategies
With the complex interaction between human and
robot, both cognitive and physical aspect of human-
robot interaction (CHRI and PHRI) have been taken
into consideration for controlling the device [114].
Different control strategies are required to suffice
the various operating mode of a rehabilitation device
(active mode, passive mode, active assist mode and
active resistive mode) [115]. During early stages of
rehabilitation, when patient’s voluntary movements
are absent, a control strategy must provide passive
training, which must be changed to active mode after
the patient would have regained the lost limb move-
ment. These two modes have also been reviewed
in literature as trajectory control or position con-
trol and assist as needed (AAN) control [116]. Assist
as needed control have been obtained with the aids
784 S. Bhardwaj et al. / Lower limb rehabilitation robotics

Table 1
Control strategies for rehabilitation robotics
Control Methods Characteristics Outcomes Issues References
strategies
Position Trajectory The strategy is used in Help to achieve Trajectory generation [122, 130]
control tracking passive training repetitive and and high control
control mode during the continuous training accuracy are key
early period of in a passive way. issues.
rehabilitation. The device follows
a predefined
trajectory.
Force and Hybrid position Consideration to joint Promote user Exact knowledge of [125, 131]
impedance and force trajectories and motivated training. the dynamical
control control force interaction to Corrections to the model is essential.
provide active movement based on
training. This virtual tunnel
strategy can be approach.
applied for
strength-based
training.
Impedance It is one of the most Enhanced Tuning of impedance [107, 121]
control widely used human-robot parameters with the
rehabilitation interaction. More rehabilitation
strategies. flexibility due to progress of the
Adjustment of the adjustable patient.
dynamic impedance.
relationship
between the joint
position and the
contact force is
possible.
EMG-based Onset-based Predict patient’s Encourages No human-robot [132, 133]
control control motion intent in self-initiated interaction during
advance. The robot movement by the movement until
assistance is patients. the next EMG
triggered when onset.
EMG reaches a
pre-estimated
threshold.
Pattern Provide continuous Continuous Large computations [56, 134]
recognition- assistance based on patient-robot are required for
based EMG signals. interaction, real-time feature
control Estimation of joint detection of extraction and
torque requirement movement phase classification.
and angular instead of just
deviations based on triggering the robot
EMG. only at the onset.
EEG-based Brain Computer It utilises a generic Used as an early High sensitivity of the [99, 135]
control interface control to enable rehabilitative signal. Overlapping
the user to realise therapy after spinal of signals generated
physical cord injury or by different cortical
interactions. EEG is stroke. regions.
recorded to train
classifiers to
distinguish between
the EEG signals of
correct commands.

of various sensors and their fusions, categorizing
it into force control, impedance control, bio-signal-
based control and adaptive control [117]. Table 1
gives an overview of control strategies for lower limb
exoskeletons developed in recent years.
Hussain et al. [118] devised an orthosis for gait
rehabilitation based on trajectory control. Boundary
layer augmented sliding control was implemented to
guide the patient leg. Mathematical models and pre-
defined gait trajectories have been used for devising
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
training [119, 120]. Emken et al. [121] demonstrated
the feasibility of teach-and-replay method in which
the therapist first teach the system by assisting the
patient and then the device replays the movement to
provide repeated therapy to the patient. In another
approach relating to the rehabilitation of hemiparetic
patients, Vallery et al. [122] used the Complementary
Limb Motion Estimation (CLME) approach to map
the movement of unimpaired leg on to the training
trajectories of impaired leg.
To augment patient motivated training (active
movement training), thereby improving the therapy
outcome, real-time assessment of performance is
required [123]. Hybrid position and force control
strategy access the position as well as the force
between the device and user to control the assistance
during training. Simon et al. [124] used a novel force
control scheme to force leg symmetry during exten-
sion exercise. The device responds by increasing the
load beyond target resistance whenever the leg asym-
metry is detected by the force plate. In gait training
exoskeleton, ALEX, developed by Banal et al. [70],
a force-field controller was used to provide assistive
torque at the hip and knee. This method was also
called virtual tunnel approach, as the patients were
guided to be in the tolerance limit of gait trajectory. A
similar approach was adopted in developing patient-
cooperative control for Lokomat [21]. Impedance
control was employed to regulate the dynamic rela-
tion between the device and the user. Many devices
such as LOPES [37] and Lokomat [125] have used
impedance control for regulating the patient gait and
promoting patient participation. A major drawback of
impedance controller is that the impedance parame-
ters must need to be changed with the rehabilitation
progress of the patient [117]. To address this prob-
lem, an adaptive impedance control was proposed by
Hussain et al. [126], which adapts itself according to
the disability level of the patient.
Bio-signals have also been used in developing
user intended control paradigm. Surface EMG and
non-invasive EEG have been used for the control.
Do et al. [99] developed a BCI interface orthotic
device, RoGO. Alternating epochs of idling and walk-
ing motor imaginary were analysed to generate the
model for predicting the walking assistance. Feasi-
bility of EEG-based control is, however, limited to
EEG sensitivity and classification accuracies [18].
EMG control strategies are mainly classified into
two types: onset detection-based control and pat-
tern recognition-based control. For HAL systems,
EMG was used to measure the joint torque assistance
785
[127, 128]. Hassani et al. [129] used EMG with knee
musculoskeletal model to control the exoskeleton.
9. Discussions
9.1. A promising approach
Apart from the other rehabilitation robotic archi-
tectures, the exoskeletons, whether tethered or un-
tethered, have better embodiment with the user. This
not only has the advantage of effectively integrating
the cognitive ability of human being [18] but also
promotes greater self-esteem compared to other aids
[136], thus improving the overall quality of life of the
disabled and elderlies [137, 138]. Based on the joint
actuation, various exoskeletons have been researched
for their efficacy towards assistance and rehabilitation
in different lower limb motor impairments.
The primary thrust of exoskeleton research has
focused on medical applications to support and reha-
bilitate neurological impairments. The notion of
using rehabilitation robotics in neurological prob-
lems is supported by the high prevalence rate of
mobility impairments caused by these disorders.
WHO has estimated neurological disorders and in
particular cerebrovascular disease, as the cause of
maximum disability and healthy life year lost in the
world [139].
Exoskeletons in the form of with and without body
weight support (BWS) system have shown the effi-
cacy in gait training and assisting mobility of SCI,
traumatic brain injury (TBI) patients and rehabilita-
tion of major trauma patients such as stroke, cerebral
palsy (CP), Parkinson disease, etc. [140–142]. Apart
from walking ability, exoskeletons have also shown
their efficacy in improving secondary gait outcomes
viz. balance, spasticity and pain [143].
9.2. Still a long way to go
Robotic rehabilitation devices, particularly exo-
skeletons, are still lying on the curve of inflated expec-
tations in Gartner Hype cycle with at least ten years
until reaching a steady level of productive use in
the real world [144, 145]. Primarily, most of the
lower limb exoskeletons are tethered and used in
controlled environments such as hospitals and reha-
bilitation centres under the supervision of medical
professionals. In the direction to restore the auton-
omy during training as well as gait assistance, only a
few overground exoskeletons (untethered) have been
786 S. Bhardwaj et al. / Lower limb rehabilitation robotics
researched such as ReWalk [33], Indigo [146] and
Ekxo [147]. However, they are still prone to the user
subjective criticism such as donning/doffing, move-
ment speeds [143], aesthetics [148, 149], prevention
of venous-lymphatic stasis and skin protection at the
interface [136] as well as engineering aspects relat-
ing to sensors, actuators, control strategies, energy
supplies, and materials [144, 150].
Although the use of robotics has shown a promis-
ing approach to rehabilitation, two major challenges
are hampering the progress. First is the incompe-
tence of the current system to achieve a compliant
modulation of the neuromuscular activity while pro-
moting a voluntary robotic control, and second is the
limited understanding of the disability induced mus-
culoskeletal changes that impede the understanding
of how the patient’s motor intentions can be best
formulated in a control strategy for robotic device
[151].
9.3. Newer dimensions to explore
Advances in the sensors, actuators, information
technology and control techniques are essential to
accelerate the success of robotic exoskeletons. Wear-
able sensors will provide a new dimension to the
human intent and motor functionality. Big data algo-
rithms will need to be incorporated to mine the
vast amount of physiological signals that will be
available in the near future. Machine learning tech-
niques may bring new control approaches to robotic
exoskeletons. Additive manufacturing will allow
customization and cost-effective approaches in man-
ufacturing exoskeleton frames and components. The
use of compliant actuators will add more safety to the
operation of exoskeletons [144, 152].
Although, the use of exoskeletons for rehabilitation
and assistance of neurological patients is clinically
and economically justified [153], a wider approach
needs to be explored for less researched non-medical
use of exoskeletons as in case of occupational work-
ers, healthy elderlies, sports, exercises and even for
the astronauts for extra-terrestrial surfaces [154]. The
use of exoskeletons for industrial usage will have
direct consequence of reduction in the incidences of
WMSDs among occupational workers by defining
reachable spaces for the tasks and supporting joint
movement.
Recently, due to the rapidly growing elderly pop-
ulation, attention has been started for providing
assistance to elderly people for carrying ADLs. There
emerged a growing urgency for assistive technologies
to help elderly people remain independent. Healthy
elderly people do not, as such, have serious problems
which demand the intervention of medical personal
except the reduced physical abilities. However, if
left unattended, the frailty leads to disabilities over
time and may even aggravate the progression of
other musculoskeletal, cardiovascular and respira-
tory pathologies [155]. Exoskeletons will be useful
in addressing the age related inabilities to promote
active and assisted living (AAL). Not only can
exoskeletons help the frail elderly, but they can also
delay the onset of frailty by providing the required
mobility, strength and endurance training [10].
9.4. Challenges
With the advent of wearable sensors and advance-
ment in actuation technology, research in robotic
rehabilitation and in particular lower limb exoskele-
tons have experienced a sustained pace over the
past decade. Most of the rehabilitation exoskeletons
(assistive/therapeutic) developed in the past were,
however, aimed towards patients with neurological
disorders (SCI and stroke), with very less empha-
sis on musculoskeletal disorders. Although wearable
robotics and exoskeletons are considered as a key
enabling technology for personalized ambulatory and
assistive solution, the technology is still in the devel-
opment phase and many factors still need to be
addressed in this domain.
One broad issue in the domain of exoskeletons in
the detection of human intention beforehand. Control
strategies promoting high and low level human-robot
interaction is very important in the drivability of
device and further to encourage patient’s recovery.
Efforts have been made in enhancing the human-
robot interaction using EMG signals. However, the
use of EMG has several limitations that are required
to be addressed in novel ways. Firstly, The EMG sig-
nals are prone to inter-subject variability that limit the
use of EMG in making a generalized muscle model.
Second, EMG is not suitable for patients with mus-
cle disorders. Third, controller dynamic performance
for real-time EMG computation. Fourth, errors asso-
ciated with rapidly changing direction of the muscle
extension during exercise/therapy. It is expected that
EMG must be introduced in the whole cycle of robot
control, which is only possible by hybrid control
strategies.
Other challenges that hinder the realization of
exoskeletons are: requirement of compact actuators,
long term power supplies, improved ergonomics and
 S. Bhardwaj et al. / Lower limb rehabilitation robotics
safety, use of lightweight materials in construction
and miniaturization of electronics for reducing the
weight.
Another factor that hinders the potential for effec-
tive improvement is lack of empathy. Empathy is
an important factor in improving therapeutic out-
come. However, machines cannot feel empathy, and
this creates a hurdle in maximizing the full poten-
tial use of robotics in treatment and assistive needs.
The exchange of emotional expression, perhaps with
a comprehensive brain-computer interface between
human and machine, will strengthen the formation of
the desired assistance relationship.
10. Conclusions
With the increasing need for a flexible healthcare
system and skill shortages, the robotic assistance to
provide rehabilitation support has generated immense
interest among researchers over the past two decades.
To achieve a better embodiment and rehabilita-
tion efficacy the biomechatronic criterion has been
accepted in the design of rehabilitation robots. This
has led to advancements in sensors, actuators, con-
trol strategies, mechanisms, materials, etc. However,
a more comprehensive approach needs to be explored
for less researched non-medical use of wearable
assistive devices as in the case of occupational work-
ers, healthy elderlies and sports. As pointed out,
the field is still open to questions of safety, user
acceptability, human-robot interaction and context-
aware control framework. As a whole, the article
is expected to provide an understanding and recent
advances in the technology of lower limb reha-
bilitation robots, facilitating the academicians and
researchers to review and realign their efforts to
maximize impact on the rapidly growing field of reha-
bilitation robotics.
Conflict of interest
The authors report no conflicts of interest
Funding
This work was supported by the Council of Sci-
entific and Industrial Research (CSIR), New Delhi
under the Senior Research Fellow (SRF) scheme. File
no. 09/112(0554)2K17.
787
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