2011 IEEE/RSJ International Conference on

Intelligent Robots and Systems

September 25-30, 2011. San Francisco, CA, USA

The Development and Testing of a Human Machine Interface for a

Mobile Medical Exoskeleton

Katherine A. Strausser and H. Kazerooni, Member, IEEE

or are passive, supported with a spring. The ankle joints are

Abstract— Current advancements in exoskeleton robotics
allow those with mobility disorders to walk again. The user
conveys his or her desired motion to the exoskeleton using a
Human Machine Interface (HMI). This allows the users to
stand up, walk, and sit down independently. Existing HMIs
require unnatural motions that inhibit the gait. The HMI
developed here uses natural gestures while ensuring the safety
of the user. This method utilizes a unique sensor suite and a
finite state automaton to allow a spinal cord injury patient to
easily use an exoskeleton for mobility.
I. INTRODUCTION
not actuated but are highly sprung in the sagittal plane and
locked out in the other degrees of freedom. This minimizes
weight and complexity while still allowing the necessary
flexibility for sitting down and standing up with the feet flat
on the ground. These degrees of freedom allow for the
exoskeleton to sit, walk, and stand while minimizing
uncontrolled degrees of freedom. Details of the
development of the exoskeleton can be found in [3]. eLEGS
is the platform used for testing the human machine interface
presented here.

S pinal cord injuries affect the quality of life for over

250,000 Americans, and approximately 11,000 more injuries
are sustained each year [1]. Spinal cord injury patients are
more susceptible to many secondary injuries that result from
pressure points or reduced blood flow as a result of their
injury. These injuries include bed sores, spasticity,
respiratory dysfunction, osteoporosis, and fractures [2].
However, these secondary injuries can be mitigated with a
device that provides the patients the ability to stand up and
walk.
A lower-extremity exoskeleton is a robotic device that can
give spinal cord injury patients increased mobility. Such a
device has two legs connected by a torso structure, which is
worn like a backpack and houses the electronics and
batteries. The exoskeleton legs are coupled to the user’s legs
by straps that are designed to minimize pressure on the
person’s skin.
The University of California, Berkeley and Berkeley
Bionics have developed eLEGS, one such lower-extremity
Fig. 1. The Medical Exoskeleton eLEGS was developed at the
exoskeleton (Fig. 1). It has four actuated degrees of
University of California, Berkeley and Berkeley Bionics.
freedom, which minimize the complexity and weight of the
machine while still providing the functionality needed. The The human machine interface (HMI) is a method by
hip and knee joints are actuated in the sagittal plane (the which the user commands the exoskeleton to the desired
direction of the walking motion). The range of motion of state. The users’ ability to communicate their intended
these joints is comparable to that of a healthy individual. motion to the robot is critical; yet finding a simple, reliable,
The other degrees of freedom at those joints are locked out and safe method to do this is one of the challenges for lower-
extremity exoskeletons.
Manuscript received March 28, 2011. This work was supported in part Existing HMIs utilize human initiated leg motion,
by the National Institute of Standards and Technology under Grant No. additional motions, or brain signals to indicate a desired
70NANB7H7046. motion. In many HMIs, such as the one used by the Human
K. A. Strausser is a graduate student in the Human Engineering
Universal Load Carrier (HULC) exoskeleton, the user begins
Laboratory at the University of California, Berkeley, Berkeley, CA 94720
USA (e-mail: kstrausser@berkeley.edu). the motion and the robot then provides support and
H. Kazerooni is a professor in the Department of Mechanical assistance. However, because these require the user to begin
Engineering at the University of California, Berkeley, Berkeley, CA 94720 the motion independently, for example by taking a step, this
USA. He is also the director of the Human Engineering Laboratory.

978-1-61284-456-5/11/$26.00 ©2011 IEEE 4911

is not suitable for spinal cord injury patients [4]. Additional
motions, such as using a keypad or moving the tongue or
arm in a specific way, are not desirable because it limits the
ability of the user to learn and use while performing other
tasks [5]. ReWalk, by Argo Medical Technologies, utilizes
both a keypad and back movements to indicate motions [6].
These back motions, while more natural than some motions,
do cause a shift in balance and may affect the user’s
stability.
Brain Machine Interfacing is a developing field which
allows brain activity to be read and translated into intended
motion. For spinal cord injured patients, this could allow the
signal to be read above the injury level and translated into a
desired motion. However, this field is still new and does not
yet have a reliable means by which to accomplish this for
walking [7].
The HMI presented here senses the user’s natural gestures
and translates them into desired robot actions while allowing
only safe transitions. These natural motions are the arm and
crutch motions that are used during walking for stability and
support. This HMI is non-invasive, easy to learn, and allows
the user to focus on other tasks while walking. Because the
HMI reads the natural motions of the user, a new user can
become proficient in using it within an hour of training.
The HMI presented here includes a set of sensors that is
worn by the user (attached to the crutches or incorporated on
the exoskeleton) and is used to determine the user’s intended
motion. The user utilizes the sensor set and crutches while
walking. The sensors are worn externally and send signals
based on the user’s pose. The signals from the sensors are
then sent to the processor which interprets the signals. The
finite state machine software uses these signals to determine
the state. The finite state machine includes all possible
motions that the exoskeleton can perform and the allowable
transitions between these states. The state is then sent to the
controller to move the robot, which moves the user. This
paper describes the details of the hardware and software
components that make up the HMI as well as testing of the
HMI system on spinal cord injury patients.
II. HMI HARDWARE
The HMI hardware consists of the set of sensors that
measure human motion to determine body pose. The
features sensed are: hip and knee angle measurements, foot
pressure sensors, arm angle, and crutch load. The
exoskeletons are usually equipped with a means to read the
knee and hip angles, but sensors to do so can be added if
they are not present in the machine. The foot also contains
sensors which determine when the user’s foot is in contact
with the ground. Each of these pressure sensors are affected
by the person’s position, but cannot be directly influenced
because the user has limited or no control over their lower
body. As a consequence, additional sensors are added that
can be directly influenced by the user’s motion. These
motions are read by the HMI to determine desired state.
The first sensor used to determine the desired state is the
arm angle sensor. The arm angle sensor reads the angle
between the upper arm and vertical in the sagittal plane.
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This HMI works with the gait commonly taught by physical
therapists by looking at the body pose during that gait. The
most stable walking gait for those with limited leg strength
is the 4-point gait (Fig. 2). This gait allows the patient to
always have a stable tripod on the ground. The sequence is
as follows: left crutch, right foot, right crutch, left foot, and
then repeat.
Fig. 2. The Four-Point Walking Gait. The user moves one crutch, then
the leg opposite that crutch. The other crutch is then moved, then the
other foot. This pattern continues throughout walking.
Users lead each step with their crutch, so their desire to
step can be determined by their arm angle. Through
experimentation, we found that the arm angle was more
easily read and had more consistent behavior from step to
step and among different users than the crutch angle. This is
because as the person swings their arm, the crutch is
frequently held perpendicular to the ground by changing the
elbow bend angle. In order to ensure that the HMI did not
require the user to change their gait or the use of the crutches
from what is commonly accepted in physical therapy, the
upper arm angle is used.
The HMI includes an arm angle sensor, which is a
standard two degree of freedom accelerometer/gyroscope
mounted to an arm band which is worn on the upper arm
(Fig. 3). The gyroscope (Analog Devices ADXRS610) has a
rate of ±300º/sec. The accelerometer (Analog Devices
ADXL203) has a range of ±1.7 g. These two components
are mounted on a single board, which ensures their proper
orientation, and then put in a case which is worn on the
upper arm. The sensors are sampled at 10 MHz. We
combine these sensors using a complementary filter, which
utilizes a low-pass filter on the accelerometer and a high-
pass filter on the gyroscope.
The arm angle sensor is calibrated by setting the 0º and
90º angles and the 0º/s2 acceleration after it is put on the
user. The zeros give the bias of the sensors while the 90º
angle gives the expected range. This allows the software to
account for any misalignment on the arm.
Once the arm angle is measured, it can be used to indicate
when the person wants to take a step by setting a minimum
threshold. The threshold is established by observing the
angle of the user’s arm when their crutch is forward to take a
step and varies by user based on crutch technique and
overall posture while walking. If the arm moves beyond the
threshold set for that user, the step is triggered. However, if
the crutches are held near the user in a standing position, a
step is not triggered.

Fig. 3. The accelerometer and gyroscope are worn on the upper arm.
The two sensors are filtered using a frequency based filter to determine
absolute arm angle.
The user’s safety is critical; therefore, the HMI must
prevent any unsafe steps. To ensure that the crutch is firmly
on the ground and bearing some of the person's weight, the
bottom of the crutch is fitted with a force sensor. This
allows a person to gesture with their arms without fear of
accidentally taking a step. To effectively perform a step,
both crutches must be firmly on the ground before beginning
any maneuver.
The crutch sensor, shown in Fig. 4, fits into the bottom of
a standard forearm crutch. There is a linear potentiometer
with a spring to measure the load. The sensor is designed to
measure between 3 and 60 lbs of force. This will allow the
crutch to reliably read when it is on the ground. The crutch
deflects only 0.5” (1.27 cm) under 60 lbs of load so that the
motion of the crutch does not inhibit walking. The minimal
deflection acts as a shock in the crutch making it more
comfortable to use.
The crutch sensor also aids the physical therapist in
ensuring that the body weight and machine loads on the
user’s arm and shoulder are not too heavy as this could cause
long term injury.
Linear
Potentiometer
Spring
Fig 4. The custom designed force sensor for the HMI fits into a standard
crutch and measures load through the crutch.
During walking, the machine needs to determine the
person’s phase of walking. Because a person’s weight
shifts over the feet as he transitions from heel strike to
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stance and then to toe off, foot sensors are an ideal way to
determine the walking phase. The foot sensors are worn
below the user’s shoe so that he can continue to wear any
leg braces or ankle foot orthosis that he may be
accustomed to wearing. The foot sensors utilize
capacitive sensors over a large area of the base where the
shoe is attached and measures the heel pressure and toe
pressure independently. This allows users of any shoe
size or weight to use the sensors. These sensors can be
embedded in the exoskeleton or added separately if the
exoskeleton does not have a foot included. This foot
sensor can then determine where the person’s weight is
and thus help determine the subject’s current walking
phase. This information, along with the other sensors, is
used by the HMI to safely transition through walking
states.
III. HMI SOFTWARE: FINITE STATE AUTOMATON
The software portion of the HMI interprets the signals
from the sensors to determine the intended state (Fig. 5).
This software uses a finite state automaton model to
determine allowable states and state transitions based on
sensor readings.
HMI Software -
Sensor + Desired Actuator
Finite State
readings + Automaton
State Commands
Fig 5. Block Diagram of HMI Software. The sensor readings and
current state information are fed to the finite state automaton. This
information allows the HMI to determine the desired state and then
control the actuators accordingly.
Because there are discrete transitions between modes of
control for continuous states, the HMI is controlled as a
hybrid system. There are many states which are shared
between both legs, such as sitting and standing, and some
which cannot occur on both legs at the same time, such as
swing. Therefore, the states of both legs are dictated by one
state machine. During walking, the state of the leg dictates
the action of each individual leg, such as a swing trajectory
or hip support during stance. In other maneuvers, such as
sitting down and standing up, the legs must act in unison. In
these modes, the same trajectory command is given to both
the left and the right side to ensure that the person is lowered
or stood symmetrically. However, each of the legs is
controlled individually such that differences in friction or
alignment are accounted for to move the joints in unison.
Safety is critical, so the state machine must prevent the
user from entering a state that could jeopardize his safety. In
order to better guard against unwanted transitions as well as
to make the search space for the states simpler, we
developed a hierarchical finite state machine. This separates
the larger modes from the individual actions in those modes.
The top level modes are sit/stand, start walk, end walk, and
walk. There are specific states from which each mode can
enter another. In sit/stand mode, for example, the user must
be in “standing” before entering “start walk”. Also, by
combining these modes, the controller for sit/stand, start
walk, and end walk can control both legs simultaneously,
whereas for walk, the states of each leg are more
independent and simply check the other state to ensure that
the system does not enter unsafe combinations.
The users don the exoskeleton by transferring from their
wheelchairs; therefore, the exoskeleton begins in the seated
state. For testing, the exoskeleton can also begin in the
standing state if an able-bodied developer puts on the robot Fig. 7. This figure shows a person in a normal walking gait [8]. The
in the standing position. From the starting state, the user can states of the shaded leg are noted. Swing is divided into knee flexion
sit or stand (Fig. 6). Once standing, the user can enter the (when the knee is bending), and knee extension (as the knee extends to
prepare for heel strike).
start walk, which starts with the feet together and moves one
foot in front in preparation for walking. From there, the user
can either walk or end walking, which brings the feet back L Swing
together. Each of these top level modes contains its own
finite state automaton which is described below.

Double Double
Stance (R) Stance (L)

R Swing

Fig 8. The walking cycle consists of the swing and stance phases.

The transitions between each of these states are guarded

by conditions of the sensors which the user can control.
Therefore, in order to transition from right double stance to
Fig. 6. The overall finite state automaton. For clarity, the states of left swing, the user must move the right crutch forward and
sit/stand are written out. The user can begin in either Standing or put weight on it. In order to protect from both legs trying to
Seated.
swing at the same time, the right foot must be on the ground.
To transition from swing to stance, the swing foot must
The walking sub-state machine is used to control the
contact the ground. Similar guards exist for all of the state
walking gait and coordinate the two legs. The state machine
transitions as shown in Table I.
is modeled after the walking cycle. The states of the
walking cycle which this HMI identifies are as follows: Table I. The guards for the state transitions ensure that the user is ready
stance, toe off, swing, and heel strike (Fig. 7). The person to take a step and will be safely supported.
begins in stance. The stepping foot lifts off of the ground at Conditions Right Left Arm Right Left Left Right
toe off. The leg then goes into swing, which is when the leg Arm Forward Crutch Crutch Foot on Foot on
Forward on on Ground Ground
is no longer contacting the ground. Swing consists of knee Ground Ground
flexion and extension while the hip swings the leg forward. State
Transitions
Heel strike occurs when the heel first makes contact with the
ground after swing. L Double   
Stance
R
The HMI divides the walking cycle into four states: left Swing
swing, left double stance, right swing, and right double
R Swing

stance. The swing state lasts from toe off until heel strike. R Double
The double stance phase occurs when both feet are on the Stance
ground and the body is shifting forward. Left (“L”) denotes R Double   
that the left leg is in front. Stance
L
Swing
L Swing

L Double
Stance

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 IV. TESTING sensory). At the time the test was done, he had about 30
This Human Machine Interface was tested on eLEGS at hours of experience using the exoskeleton, though most of
the University of Virginia Gait Laboratory and at Berkeley this was before the development of the HMI. Since the time
Bionics. Sensor information was collected from the between the steps is dependent on the user’s ability to shift
exoskeleton processor. their weight forward in preparation for the next step, for a
The first test was done with an able-bodied subject who is spinal cord injury subject, the effectiveness of the HMI in
familiar with walking in eLEGS with and without the HMI. terms of timing steps is demonstrated by the difference
The step speed was set the same for both runs. Therefore, between when the HMI starts the step and when the Physical
the only variation in walk speed was the length of the double Therapist or other operator would trigger the step using the
stance phase. The double stance phase length depends on control pad.
how long it takes the person to shift their weight forward so
that the trailing leg can flex. As the weight shifts forward,
the trailing heel lifts off of the ground. This can be
measured by the exoskeleton foot sensors. In normal
walking, the heel coming off of the ground immediately
precedes the knee flexion and the start of the swing phase.
However, because the eLEGS system is waiting for a trigger
to start the swing, there is a delay. Decreasing this delay is
essential to making the walking natural and smooth.
eLEGS can be operated in “PT Mode”, which is when the
physical therapist or operator pushes a button to initiate the
step. Initial tests were done with able bodied users so that
the effect of learning how to use the machine did not
influence the timing. For an able bodied user walking in PT
Mode, the average time between the heel coming off of the
ground and the swing phase beginning was 0.938 seconds Fig. 10. An able bodied user using eLEGS in HMI mode to trigger
steps. The time in double stance is decreased in comparison to the PT
(Fig. 9). This can be seen in the delay between the heel triggered steps.
pressure going to zero and the leg state switching to swing
(shown as 1). Fig. 11 shows the transition from stance to swing when
the step was triggered by the physical therapist. However,
the point at which the HMI would have triggered the swing
state is also shown. There was very little delay between the
swing phase when the physical therapist triggered it and
when the HMI would have initiated the step. The second
step was delayed because the subject was not leaning on the
crutch. The average delay over all of the steps is only 0.25
seconds.

Fig. 9. The swing phase is triggered by a push of a button (PT Mode)

rather than by the HMI. The heel pressure value shows when the heel
lifts off of the ground.

The user then triggered the step using the HMI mode.
The average time after the heel is off the ground was only
.474 seconds. This improvement indicates that the walk is
more natural in HMI mode and is also faster. In fact, in 16
seconds, using HMI mode, the user was able to take 6 steps
as compared to the 4 steps that he could take using the PT
mode. Fig. 11. The steps shown here were triggered by a physical therapist.
The exoskeleton was also tested on spinal cord injury However, the dashed line shows when the HMI would have initiated the
subjects. Subject 1 is a 24 year old male. He has a spinal step. The lag between the steps averages only 0.25 seconds.
cord injury at T9 resulting in complete paralysis (motor and

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 The HMI is intuitive and easy to learn to use. In order to
test this, four new users tested eLEGS with the HMI (Table
II). The subjects were introduced to the exoskeleton and the
HMI during a two-hour session. During this session,
anatomical measurements were taken and the exoskeleton
was adjusted for them. They were given a demonstration of
the exoskeleton and then began walking with the device with
a walker for support. Once they were comfortable with the
walker, they began using forearm crutches. Those subjects
who were comfortable on the forearm crutches were taught
to use the HMI. Out of eight subjects, four were able to
progress to using the HMI. All four of these subjects were
able to successfully use the HMI to walk in eLEGS. The
subjects presented a range of injury levels and completeness
and yet were able to use the HMI without adjustments to the
program.

Table II. Five subjects with varying spinal cord injury levels and
completeness have tested the HMI with eLEGS. The level of injury
describes which vertebra was injured. The ASIA completeness level is a
method to describe the how complete the injury is and ranges from A
(complete) to E (normal). C indicates some muscle or sensory function.
Subject Injury Type Injury ASIA
Number Level Completeness
1 Paraplegic T9/10 A safe, and intuitive method to control eLEGS. The interface
2 Friedreich's ataxia N/A N/A
3 Spinal Cyst C7/T10 C exoskeleton. The HMI offers more natural gait at a speed
4 Paraplegic T5/6 A closely resembling that of an able bodied individual using
5 Quadriplegic C5/6 C the exoskeleton by starting the swing phase soon after the
Subject 1 has the most experience using the HMI and is
comfortable using the exoskeleton with minimal spotting.
Subject 2 is a motor incomplete spinal cord injury patient
with Friedreich's Ataxia. Subject 2 was introduced to the
exoskeleton at the beginning of a 2-hour long session. He
walked in the exoskeleton for about 30 minutes. After this
time, he was introduced to the HMI and walked about 50
feet before data was taken. The remainder of the subjects
also used the exoskeleton and HMI during similar sessions.
All five of the subjects were able to quickly learn the
HMI. The increased time practicing using the HMI
improved Subject 1’s performance. For example, in
comparison to Subject 2, both had an increased time
between heel off and the step as compared to the able–
bodied user; however, this time was decreased in the
experienced user (Subject 1). While the new user had an
average time of 0.859 seconds, the experienced user was
able to reduce the lag time to 0.590 seconds.
Fig. 12 shows a comparison of the knee angle of the
experienced user to a new user (Subject 2). Both users were
able to maintain a consistent cadence to their steps, which
indicates that the HMI, though slower than walking for an
able-bodied subject, is steady. This consistent cadence
indicates the naturalness of the walk as the user is not
struggling to shift their weight or trigger the next step.
Fig. 12. Comparison of the HMI Triggered Steps for a New User and an
Experienced User.
V. CONCLUSION
The HMI offers users with spinal cord injuries a reliable,
uses minimal additional sensors beyond those on the
heel lifts off of the ground. The HMI is easy to learn as
indicated by the fact that all five of the subjects were able to
quickly learn how to use the HMI with eLEGS.
VI. REFERENCES
[1] ”Spinal Cord Injury Facts and Statistics.” The University of Alabama
National Spinal Cord Injury Statistical Center, March 2002.
[2] Walter, James S., et al. “A Database of Self-Reported Secondary
Medical Problems Among VA Spinal Cord Injury Patients: Its Role in
Clinical Care and Management.” Journal of Rehabilitation Research
and Development. Vol 39, No 1, Jan/Feb 2002.
[3] Strausser, Swift, Zoss, Bennet, Kazerooni. “Mobile Exoskeleton for
Spinal Cord Injury: Development and Testing.” 4th Annual Dynamic
Systems and Controls Conference. Arlington, VA. Oct 31-Nov2,
2011.
[4] Amundson, K. (December 2007). Control and Energetics of Human
Exoskeleton. Ph.D. Thesis. University of California, Berkeley: USA.
[5] R. Vaidyanathan, B. Chung, L. Gupta, H. Kook, S. Kota, and J. West.
Tongue-movement communication and control concept for hands-free
human-machine interfaces,” IEEE Trans. On Systems, Man, and
Cybernetics—Part A: Systems and Humans. 37(4). 533-546.
[6] Argo Medical Technologies. "Products." Welcome to Rewalk.com.
2010. Web. 14 July 2011. <http://rewalk.com>.
[7] Lebedev, M., et al. “Future Developments in Brain-Machine Interface
Research.” Clinics. 66(S1): 25–32. 2011.
[8] Rose, J. and Gamble, J. Human Walking. Baltimore, Lippincott
Williams & Wilkins, 2005.

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