Review Article

Proc IMechE Part H:

J Engineering in Medicine
1–11
State-of-the-art robotic devices for Ó IMechE 2017
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DOI: 10.1177/0954411917737584

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Shahid Hussain1, Prashant K Jamwal2 and Mergen H Ghayesh3

Abstract
There is an increasing research interest in exploring use of robotic devices for the physical therapy of patients suffering
from stroke and spinal cord injuries. Rehabilitation of patients suffering from ankle joint dysfunctions such as drop foot is
vital and therefore has called for the development of newer robotic devices. Several robotic orthoses and parallel ankle
robots have been developed during the last two decades to augment the conventional ankle physical therapy of patients.
A comprehensive review of these robotic ankle rehabilitation devices is presented in this article. Recent developments
in the mechanism design, actuation and control are discussed. The study encompasses robotic devices for treadmill and
over-ground training as well as platform-based parallel ankle robots. Control strategies for these robotic devices are
deliberated in detail with an emphasis on the assist-as-needed training strategies. Experimental evaluations of the
mechanism designs and various control strategies of these robotic ankle rehabilitation devices are also presented.

Keywords
Ankle robots, robotic orthoses, parallel robots, mechanism design, actuation, control strategies, stroke

Date received: 13 March 2017; accepted: 26 September 2017

Introduction therapeutic procedures which are often based on per-

Neurologic impairments such as stroke and spinal cord
injuries (SCI) cause damage to the functional mobility
of survivors and affect their ability to perform activities
of daily living (ADL). Impairments to the lower limb
and consequent gait functions disorders are of prime
concern. Drop foot is one of the most common gait
dysfunctions arising from the neurologic injuries, espe-
cially, stroke.1,2 Physical therapy is provided for the
rehabilitation of patients suffering from drop foot.3,4
This process involves providing repetitive exercises to
the ankle plantar and dorsiflexion muscles so that the
foot clearance during the swing phase of gait cycle
could be reinstated.5 However, ankle is a complex ana-
tomical joint producing motion with 3 degrees of free-
dom (DOFs), namely, plantar/dorsiflexion, inversion/
eversion and abduction/adduction. Repetitive physical
therapy sessions are required to reinstate the lost ankle
function in terms of ranges of motions and strengths.
Conventionally, manual physical therapy with elas-
tic bands is provided for the correction of drop foot.
However, it has many limitations such as, inconsistency
in the treatment owing to long sessions of repetitive
and monotonous trainings, subjectivity in the
ception instead of an objective evaluation of clinical
data.6 Consequently, robotic ankle rehabilitation
devices are gaining recognition among the rehabilita-
tion engineering community for the treatment of drop
foot and other neurologic impairments.7 Several
robotic devices have been developed to provide ankle
therapy.7 These robotic devices can provide repetitive,
systematic and prolonged ankle rehabilitation treat-
ment as compared to the manual therapy. Moreover,
owing to the recent advancements in the design, these
1
School of Mechanical, Materials, Mechatronic and Biomedical
Engineering, Faculty of Engineering and Information Sciences, University
of Wollongong, Wollongong, NSW, Australia
2
Electrical and Electronic Engineering Department, Nazarbayev
University, Astana, Kazakhstan
3
School of Mechanical Engineering, Faculty of Engineering, Computer and
Mathematical Sciences, The University of Adelaide, Adelaide, SA,
Australia
Corresponding author:
Shahid Hussain, School of Mechanical, Materials, Mechatronic and
Biomedical Engineering, Faculty of Engineering and Information Sciences,
University of Wollongong, Northfields Ave., Wollongong, NSW 2522,
Australia.
Email: shussain@uow.edu.au
2 Proc IMechE Part H: J Engineering in Medicine 00(0)
robotic devices can provide motions to the ankle joint
in multiple DOFs without physical therapists’
intervention.
These robotic ankle rehabilitation devices could be
divided into two categories: robotic orthoses or exoske-
letons and platform-based parallel ankle robots.
Robotic orthoses or exoskeletons are the devices which
work in close proximity of the patients’ joint and are
wearable.8,9 These robotic orthoses are used for the
treadmill or over-ground walking by the patients dur-
ing the rehabilitation process. Platform-based ankle
robots are generally parallel robots and are used by the
patients in a seated position.10–13 These parallel robots
are capable of imparting motion to the ankle joint in
multiple DOFs.
Initial prototypes of these robotic orthoses and par-
allel robots were powered by electromagnetic actua-
tors7,14–17 which have undesirable high end-point
impedance (i.e. stiffness) and can provide fewer DOFs
as compared to the anatomical DOFs of the ankle
joint.9 Development of control algorithms for these
ankle rehabilitation robots is also an active field of
research. The conventional control algorithms devel-
oped for these robotic orthoses and parallel ankle
robots used to guide the patients’ ankle joint on prede-
fined trajectories without taking into account the dis-
ability level and progress made by the patients.15,16,18
Recently, significant research efforts have been made
to improve the mechanism design, actuation and con-
trol algorithms for these robotic ankle orthoses and
parallel ankle robots.6 The goal behind the current
research is that the design of these robotic devices
should provide naturalistic motion patterns to the neu-
rologically impaired patients, and the actuation system
used with these robots should provide a smooth and
safe human–robot interaction.6 The goal for the devel-
opment of advanced control algorithms is to customize
robotic assistance according to the disability level and
stage of rehabilitation of neurologically impaired
subjects.19,20
This article presents a review on the design and con-
trol aspects of the existing robotic ankle orthoses and
parallel ankle robots. Mechanism design along with the
actuation concepts developed for these devices are dis-
cussed in detail. Control algorithms developed for both
kinds of ankle rehabilitation devices are also presented
with a particular emphasis on assist-as-needed (AAN)
control strategies which can provide customized rehabi-
litation treatments. This article attempts to provide fur-
ther updated version of the previous review published
by Jamwal et al.7 The robotic orthoses developed for
the rehabilitation of multiple joints such as Lokomat21
or Active Leg Exoskeleton22 are not a part of this
review. Also, the robotic orthoses and parallel robots
incorporating functional electrical stimulation3,23 and
brain–computer interface24 are excluded from the
review being presented here. Furthermore, the prelimi-
nary design and control developments of ankle robots
published in the form of conference proceedings and
presentations are also not considered in the review. The
article is organized as follows.
In section ‘‘Ankle robot mechanism design,’’ the
mechanism designs of robotic orthoses and parallel
robots along with their actuation concepts are pre-
sented. In section ‘‘Ankle robot control strategies,’’ var-
ious control strategies developed for these robotic
devices are revisited and discussed in detail. In section
‘‘Experimental evaluations,’’ the experimental evalua-
tions of the design and control strategies of these
robotic devices are discussed. Section ‘‘Discussion’’ pre-
sents a discussion on the state-of-the-art research in the
robotic orthoses and parallel robots employed for
ankle rehabilitation.
Ankle robot mechanism design
The mechanism design of robotic orthoses and parallel
robots is an important aspect of robot-assisted ankle
joint rehabilitation. The purpose of the robotic devices
is to provide physical therapy so that the patients can
regain their ankle muscular strength and walking cap-
abilities such as foot clearance as close to the natural
gait as possible. For this reason, the kinematic and
dynamic design of these robotic devices is of prime
importance to the rehabilitation engineering commu-
nity.7,11,25 A great emphasis has recently been placed on
selecting the appropriate DOFs for these robotic
orthoses5 and parallel robots7,11,25 so that they can pro-
vide naturalistic ankle therapy to the patients. At the
same time, the actuation of these robotic devices is an
important and emerging field of research. Traditionally,
the robotic orthoses5,9 and parallel robots10,15 were
powered by bulky electromagnetic actuators with high
end-point actuator impedance and therefore were not
considered safe for applications involving human–robot
interaction. Recently, a greater emphasis has been
placed on the development of robotic orthoses8,26 and
parallel robots powered by intrinsically compliant
actuators.6 In this section, a detailed description of the
ankle robots mechanism design and actuation methods
is provided.
Ankle robotic orthoses
In order to assist the drop foot gait, a robotic ankle-
foot orthosis (AFO) has been developed (Figure 1(a))
at the Massachusetts Institute of Technology (MIT).9
The robotic orthosis is based on a conventional passive
AFO comprising a metallic hinge ankle joint.9 The con-
cept of series elastic actuators (SEA)28 is used in the
design of robotic AFO. The SEA has a spring in series
with a brushless direct current (DC) motor. Six force
sensors are used to measure the ground reaction force
(GRF) for control purposes. The robotic AFO pro-
vides motions in the sagittal plane and mainly helps in
avoiding the foot drag during the swing phase and foot
slap during the stance phase of the gait cycle.
Hussain et al.
Figure 1. (a) MIT’s AFO,9 (b) MIT’s AnkleBot5 and (c) University of Michigan AFO.27
Another instance of ankle robot system, AnkleBot,
has also been developed at the MIT to assist the drop
foot gait (Figure 1(b)).5 The AnkleBot mechanism has
3 DOFs, and can provide, plantar/dorsiflexion, inter-
nal/external rotation and inversion/eversion to the
ankle joint during treadmill or over-ground walking
and while sitting. Two of these DOFs are actuated
while the internal/external rotation is passive and is
mostly achieved by the rotation of the leg. Two brush-
less DC motors are employed to actuate the AnkleBot.
Plantar/dorsiflexion is produced if the motors push/pull
in the same direction, and inversion/eversion motion is
produced if the motors push/pull in the opposite direc-
tion. The developers of AnkleBot have tried to utilize
the concept of low actuator end-point impedance in
order to provide compliant actuation for safe human–
robot interactions.5 Recently, a scaled down version of
AnkleBot for pediatric rehabilitation (pediAnklebot)
has been developed.17 The pediAnklebot provides
actuation and motion in the same DOFs as of the
AnkleBot.17
An intrinsically compliant and light-weight AFO
has been developed at the University of Michigan to
assist the neurologically impaired patients as well as to
study the biomechanical parameters of ankle joint
(Figure 1(c)).8,27,29 The AFO is made of carbon poly-
meric composites and has a single DOF hinge joint for
providing plantar/dorsiflexion motion. The AFO is
powered by pneumatic muscle actuators (PMAs) which
are intrinsically compliant and have high power/weight
ratio as compared to conventional electromagnetic
actuators. However, since the PMA can only provide
unidirectional force, two PMA are used in an antago-
nistic configuration to provide the ankle plantar/dorsi-
flexion motion.
A tripod-based parallel robotic mechanism has been
developed at the Arizona State University for ankle
joint rehabilitation during walking.30 The robotic
device provides motions for the plantar/dorsiflexion
and inversion/eversion using PMA as actuators.30 A
distinct feature used here is that springs are used in
3
conjunction with PMA to obtain bidirectional forces.
This modification helps in reducing number of actua-
tors for the ankle robot. A powered AFO has also been
developed at the Arizona State University.31,32 The
AFO utilizes the concept of SEA in order to provide
movement assistance to the sagittal plane motions dur-
ing walking.31,32 The AFO also consists of a single
DOF hinge joint for providing sagittal plane rotations.
A bio-inspired AFO has been recently developed for
the rehabilitation of neurologically impaired patients.26
The AFO is also powered by four PMA which provides
plantar/dorsiflexion and inversion/eversion motions.
The PMA are connected to the knee joint by utilizing
artificial tendons. The mechanism of the AFO is
designed on the concept of soft structure which allows
possible naturalistic motions of the ankle and foot.26
The anatomy of the lower leg has been considered and
emulated while designing the bio-inspired AFO.
Another portable powered AFO has been developed to
provide gait assistance for the ankle plantar/dorsiflex-
ion motion.33 A bidirectional rotary pneumatic actua-
tor is used with a portable compressed carbon dioxide
supply for powering the AFO. A robotic exoskeleton
similar to University of Michigan’s AFO has also been
developed at Ghent University to study the biomecha-
nical parameters of ankle joint.34,35 The AFO provides
actuation for plantar/dorsiflexion motion by utilizing
the PMA.
A reconfigurable robotic ankle exoskeleton, Assist
On-Ankle has recently been proposed for the physical
therapy of patients suffering from neurologic injuries.36
Two modes, namely, 3-RPS (revolute–prismatic–spheri-
cal) and 3-UPS (universal–prismatic–spherical), have
been selected after a careful study of kinematics and
optimization performed to meet the design require-
ments of Assist On-Ankle.36 The reconfigurability aids
in repeatedly changing and rearranging the components
of the robotic exoskeleton. A Bowden cable–based SEA
has been utilized to power the Assist On-Ankle. An
electrohydraulic-actuated AFO has also been proposed
in the literature for human motion analysis.37 A hybrid
4 Proc IMechE Part H: J Engineering in Medicine 00(0)
actuation system comprising servo motor and hydraulic
cylinder powers the plantar/dorsiflexion motion.37
Parallel ankle robots
Ankle is a complex anatomical joint, and majority of
the robotic orthoses designed for the ankle joint can
only provide actuation for plantar/dorsiflexion and
inversion/eversion motions during walking. In order to
overcome this limitation and provide actuation to all
three major DOFs of the ankle joint, parallel robotic
mechanisms have been designed. These parallel ankle
robots are platform-based robotic devices and provide
physical therapy while the patients are in a seated
position.
A Stewart platform–based parallel mechanism38 has
been developed at Rutgers University for the rehabilita-
tion of patients suffering from neurological injuries15
and is more commonly known as Rutgers Ankle.
During physical therapy sessions, the patients put their
feet on the top platform of the Rutgers Ankle where it
is secured by the use of braces and bands. The Rutgers
Ankle is a 6-DOF platform and provides motions to
the ankle joint in all anatomical DOFs. The Rutgers
Ankle is powered by six double-acting pneumatic cylin-
ders and is equipped with six linear potentiometers as
position sensors and a six-axis load cell for force mea-
surement.15 A reconfigurable parallel robotic mechan-
ism has been proposed for physical therapy of ankle
joint.39 This reconfigurable robot consists of a 4-DOF
parallel mechanism with two parallel platforms to pro-
vide plantar/dorsiflexion and inversion/eversion
motions to the ankle joint. Pneumatic cylinders have
been used to power the parallel mechanism, and the
patients’ foot is secured on the top platform during
physical therapy sessions.39
A redundantly actuated parallel mechanism for
ankle rehabilitation robot (ARBOT) has been devel-
oped at the Istituto Italiano di Tecnologia, Genoa
(Figure 2(a)).10,20,41 The parallel mechanism provides
actuation to the plantar/dorsiflexion and inversion/
eversion motions of the ankle joint. The ARBOT con-
sists of three identical active limbs and a passive central
Figure 2. (a) ARBOT,20 (b) robotic wobble board40 and (c) parallel ankle robot.6
strut. A brushed DC motor–based linear actuation
mechanism has been developed to power the three
active limbs. A cable-driven systems of pulleys has been
utilized to convert the rotatory motion of DC motors
to the liner motions of a piston sliding in the cylinder.10
Optical encoders and a six-axis force sensor have been
incorporated in the design for the measurement of posi-
tion and human–robot interaction torque. Like Rutgers
Ankle, the patients’ foot is placed on the top platform
of the parallel mechanism and is secured by the use of
braces and bands.
The concept of redundantly actuated 3-RUS/RRR
parallel mechanism for ankle rehabilitation has also
been developed at the Beijing Jiaotong University.42
The proposed parallel mechanism can provide actua-
tion to the 3 DOFs of the ankle joint. It is proposed to
be driven by electric motors and gear arrangement. The
patients are asked to place their foot on top of the par-
allel mechanism during physical therapy. The prototype
is still in the development phase and only computer-
aided design (CAD) has been reported in the litera-
ture.42 A robotic wobble board–based system has been
developed to provide ankle joint physical therapy
(Figure 2(b)).40 It provides actuation to the 4 DOFs of
the ankle joint. Four low-voltage vibration motors have
been positioned underneath the patients’ sandal area.40
A three-axis accelerometer has been incorporated in the
design. The patients are required to place their foot on
top of the robotic wobble board during physical
therapy.
A 9-DOF hybrid parallel robot has been proposed
for ankle rehabilitation at the University of
Birmingham.43 The parallel robot consists of two seri-
ally connected moving platforms and one stationary
platform. The prototype is still in the development
phase, and only CAD design and its optimization have
been reported in the literature. The patients’ feet are
secured on the top platform of the parallel mechanism
during physical therapy.43 A low-cost 3-PRS (pris-
matic–revolute–spherical) parallel manipulator has also
been proposed for ankle joint rehabilitation.44 The par-
allel manipulator can provide actuation to the plantar/
dorsiflexion and inversion/eversion motions. An
Hussain et al.
orthopedic boot worn by the patient has a force sensor,
and the patient is required to put his/her foot along
with the boot on the parallel robot. The parallel
mechanism consists of three active legs, and each leg is
powered by a brushless servo DC motor.44
Most of the platform-based ankle robots require the
patient’s foot to be placed on top of a platform which
is maneuvered by actuators placed underneath. These
designs resulted in coupled motions of the shank and
the foot which further give rise to control-related prob-
lems. In order to isolate or decouple the ankle joint
from the shank, it is required that the shank be fixed
with respect to the moving platform. Aiming at this
design improvement, an ankle rehabilitation robot is
developed13,45 wherein the shank is fixed within the
space provided in the top platform and the foot placed
on the base platform which also forms the robot end
effector. The base platform consisting the patients’ foot
is actuated while the top platform remained stationary.
Motion and moments of the end effector about the true
ankle center therefore can, respectively, provide accu-
rate indications of the relative orientation and moments
between the user’s foot and shank. However, this ankle
robot is actuated using linear actuators powered by
brushed DC motors which are heavy and stiff, and a
compliant motion is difficult to obtain.
A light-weight adaptive ankle rehabilitation robot
was later developed which has actuators placed parallel
to the shinbone of the subject while the foot is attached
to the end effector of the robot (Figure 2(c)).6,11,25 As a
result, positions of the ankle joint and the shinbone
remain unaltered during the course of the treatment.
This ankle robot is light in weight and remains compa-
tible to the patients’ ankle joint during ankle motions
since it uses inherently compliant and light-weight
PMA. Owing to its biologically inspired design and use
of compliant actuators, the robot has been considered
back-drivable and safe to use.
A mechatronic device MecDEAR has been pro-
posed for the rehabilitation of ankle motor function.16
MecDEAR is a platform-based robotic device and pro-
vides motions to the ankle joint in the sagittal plane
and is powered by electric motors. Actuation is trans-
ferred from the motor by utilizing a belt and pulley
arrangement. MecDEAR does not fall under the cate-
gory of parallel robotic mechanisms. The patients place
their foot on top of the MecDEAR to perform robotic
ankle therapy. A platform-based robot for ankle joint
rehabilitation and evaluation has also been devel-
oped.46 The robot provides plantar/dorsiflexion
motions using a servo motor for providing rotational
motion to a hinge joint.46
Ankle robot control strategies
Control strategies for the robotic ankle orthoses and
parallel ankle robots are developed to repetitively guide
the patients’ ankle joint on anatomically and
5
ergonomically feasible trajectories so that the patients
can regain lost ranges of motion and muscular
strength. Development of these control strategies has
also been an important area of research in the domain
of robot-assisted ankle rehabilitation. These control
strategies normally fall under two categories, namely,
trajectory tracking control and AAN control.
Trajectory tracking control
During the trajectory tracking control, patients’ foot is
moved about the ankle joint on the reference trajec-
tories with the help of robotic orthoses and parallel
robots. These reference trajectories are normally
obtained from the healthy subjects by utilizing the
motion capture system in the biomechanics labs or
other motion recording devices.47 The patients’ disabil-
ity level or the effort incorporated is not usually taken
into consideration during the pure trajectory tracking
control.
A trajectory tracking control based on the propor-
tional control law has been developed for the Arizona
State University robotic prototype.30 The desired orien-
tation of the ankle joint is incorporated in the trajectory
tracking control algorithm, and the desired deflection
of the spring over muscle actuator is obtained from the
parallel kinematics.30 A trajectory tracking control
algorithm based on the linear time-invariant (LTI) law
has also been proposed for the bio-inspired AFO.26
The purpose of LTI law was to guide the human sub-
jects’ ankle joint on reference trajectories while taking
into account the disturbances caused due to the non-
linear behavior of PMA. The human–AFO system has
been considered as a black box from which the input–
output dynamic mapping was identified using a sub-
space system identification technique.26
A trajectory tracking controller for portable pow-
ered AFO has been developed to provide assistance for
the ankle plantar/dorsiflexion motion.33 The dorsiflex-
ion assistance could be tuned to the needs of individual
patient based on their weight. The magnitude and tim-
ing of the torque provided by the powered AFO has
been controlled based on the events of the gait cycle
such as loading response, mid-stance, terminal stance
and swing.33 The force sensors embedded in the foot
piece of the AFO were used to detect these events and
trigger the assistance. Ghent University’s robotic exos-
keleton also provides trajectory tracking control based
on the detection of phases of gait cycle.34,35 Detailed
description of the Ghent University’s robotic exoskele-
ton control scheme has not been provided in the
literature.
A trajectory tracking control scheme has been imple-
mented for the preliminary prototype of Rutgers
Ankle.15 A conventional approach of control of pneu-
matic actuators48 has been tailored to meet the require-
ments of the parallel robot. The control system design
allowed for the position and force control of the proto-
type. Position control has been used for guiding the
6 Proc IMechE Part H: J Engineering in Medicine 00(0)
ankle joint on reference trajectories, and force control
is used for maintaining the necessary forces and torques
at the ankle joint.15 A golf-based trajectory tracking
control scheme has also been developed for robotic
wobble board–based system.40 A proportional control-
ler converts the pitch and roll values received from the
wobble board to a velocity vector that displaces the ball
in a two-dimensional (2D) world.40
A trajectory tracking control based on iterative fuzzy
logic methodology for the parallel ankle robot powered
by PMA has been developed.6,18 The purpose of the
trajectory tracking control was to guide the ankle joint
on reference trajectories while dealing with the non-
linear and time-varying behavior of PMA. In order to
model the dynamic behavior of PMA, initially, a fuzzy
feedforward controller, tuned using genetic algorithm
(GA), was developed. Later, this controller was inte-
grated as an inverse plant model into an iterative fuzzy
control scheme for the position control of the ankle
robot.
AAN control
Various AAN control algorithms have been designed
for the robotic ankle rehabilitation orthoses and paral-
lel ankle robots during the past decade. The concept
behind the development of AAN algorithms is to mod-
ify the robotic assistance according to the disability
level and effort put by the patients during the rehabili-
tation process.7 If the patients show some progress and
recovery by incorporating their muscular strength, the
robotic assistance is reduced and vice versa.
An AAN control scheme based on adaptive control
law has been developed for MIT’s robotic AFO.9 A
finite-state machine–based control law has been devel-
oped to prevent the foot slap during the stance phase
and avoid foot drag during the swing phase of gait
cycle. GRF has been measured to detect these phases
of gait cycle. Based on the magnitude of GRF, the con-
trol scheme can provide zero, constant and variable
impedance control levels to the patients depending on
their disability level. During zero-impedance control
mode, the patients can walk freely in the AFO without
any robotic assistance, whereas during variable impe-
dance control, the stiffness of SEA is adjusted in order
to provide AAN training.9 AAN control for Assist On-
Ankle has been developed in the form of a cascaded
force, velocity and impedance controller.36 The impe-
dance values decided by the physical therapist impose
the desired relationship between the applied force and
applied velocity of the SEA.36
An AAN control scheme based on the simple impe-
dance control law has also been developed for MIT’s
AnkleBot.5 The impedance control scheme consists of
a programmable reference ankle trajectory, program-
mable proportional gain in the form of a controllable
torsional stiffness and a programmable derivative gain
for torsional damping in series with torsional stiffness.5
The human torque component is added to the robot
applied torque in order to increase or decrease the net
applied robot torque depending upon the effort incor-
porated by the patients.5 A similar impedance control
scheme has also been utilized for the pediAnklebot.17
Myoelectric (electromyography (EMG)) activity has
been utilized for the AAN control of University of
Michigan’s AFO.29,49 During the preliminary EMG-
based control strategy, the activity of soleus muscle has
been measured to control the plantarflexion assistance
of the AFO.49 A proportional control law is used to
switch the pneumatic valves on/off based on the ampli-
tude of soleus. Later, the EMG activity of medial gas-
trocnemius has been used to proportionally control the
plantarflexion provided by the AFO.29
AAN robotic training by ARBOT has been devel-
oped based on the impedance control law.10,20 Initially,
an extended compliance control algorithm has been
proposed.10 The compliance controller provides motion
assistance or resistance in the direction of patients’
effort. Force/torque sensors have been mounted on the
top platform of ARBOT to measure the human–robot
interaction. Controllable stiffness and damping has
been utilized to implement the impedance control law
as explained above for MIT’s AnkleBot. Later, an
admittance control scheme has been developed for
ARBOT.20 The goal of the admittance control law is
also to modify the robotic motion as desired by the
patients. Spring and damper model parameters have
been adjusted to tailor the robotic assistance according
to the disability level of individual subjects.20 An impe-
dance control scheme has been developed for the 4-
DOF parallel ankle robot.39 The impedance control
scheme is implemented in the form of a cascaded posi-
tion and force controller. Different range of exercises
has been designed, and the impedance values are
adjusted accordingly by the physical therapist.
Impedance control–based AAN robotic ankle reha-
bilitation strategy has been developed for the parallel
robot powered by PMA.19 The impedance control
scheme modifies the robotic assistance according to the
active muscular contributions of the human subject.
Inverse dynamics algorithm has been developed to
extract the active muscle contributions of the human
ankle complex from the remaining passive and inertial
effects of the combined human–robot system. A bound-
ary layer–augmented sliding mode control has been
used as a basic position controller to compensate for
the non-linear and time-varying behavior of PMA. The
active muscle torque of human subjects is fed to a pro-
portional torque controller which modifies the robotic
assistance accordingly. The impedance control algo-
rithm has four modes, namely, zero-impedance control
mode, position control mode, impedance control mode
with low compliance and impedance control mode with
high compliance.19
Hussain et al.
Experimental evaluations
The experimental evaluations of ankle orthoses and
parallel ankle robot designs along with their control
algorithms are an important aspect.6,7 For most of the
robotic devices, the preliminary evaluations are carried
out with neurologically intact subjects with no prior
history of neurologic impairments in order to evaluate
and improve the mechanism design and control algo-
rithms. Subsequently, the experimental investigations
with neurologically impaired patients are also carried
out to establish the therapeutic efficacy of the robot-
assisted ankle training. Experimental evaluations of the
above-mentioned robotic orthoses and parallel robots
are discussed in this section.
MIT’s robotic (AFO) and the AAN control scheme
have been evaluated with two subjects suffering from
unilateral drop foot condition.9 Kinematic and kinetic
data of two participants have been measured in the
biomechanics lab while the subjects walked at slow,
self-selected and normal cadence. The artificial neural
network (ANN) control of robotic AFO has reduced
the foot slap and allowed greater powered plantar flex-
ion.9 MIT’s AnkleBot has been evaluated with five
healthy subjects and five stroke survivors.5 Treadmill
and over-ground evaluations have been carried out,
and a motion capture system has been used to monitor
the kinematics of ankle-foot complex. Encouraging
results of the use of AnkleBot and impedance control
scheme has been achieved.5 Later, the AnkleBot has
also been evaluated with eight stroke survivors.50
Improvements in the cadence, paretic ankle motor con-
trol and paretic single support have been observed.50
AnkleBot has also been evaluated for the treadmill
waking and seated position with stroke survivors.51
The study confirms that AnkleBot and the impedance
control scheme can adapt the assistance according to
the changes in patients’ performance.51
Experimental evaluations of pediAnklebot and the
impedance control scheme17 have been carried out with
three children suffering from cerebral palsy. Interactive
video games were included to encourage the children to
participate more actively in the training process.
Significant improvements have been recorded in the
performance metrics which are used to assess implicit
and explicit motor function.17 University of Michigan’s
AFO has been evaluated with healthy subjects to deter-
mine the performance of the PMA as well as EMG-
based control.8,27,29,52,53 Both the over-ground and
treadmill walking have been performed with AFO, and
it has been recommended that the anatomical morphol-
ogy needs to be considered while determining the
robotic orthoses design and control system.52,53 The
spring over muscle-based actuator robotic orthosis30
and bio-inspired AFO26 have been evaluated with one
healthy subject and provided satisfactory hardware and
control performance of walking on a treadmill. The
powered AFO has been evaluated with three stroke
7
survivors for treadmill and over-ground walking.32
Improvements in cadence, ankle range of motion and
power generation capabilities have been recorded after
3 weeks of training with the powered AFO.32
Portable powered AFO has been evaluated with one
neurologically impaired and three healthy subjects.33
An increase in the vertical ground reactions force has
been recorded during the second half of stance phase
for the neurologically impaired patient.33 Ghent
University’s AFO34,35 and Assist On-Ankle36 have been
evaluated with healthy subjects for different kinematic
modes and design measures such as the range of
motions and impedance control performance with vari-
able impedance values. Satisfactory performance
results have been achieved which shows the efficacy of
these orthoses.34–36
Rutgers Ankle has initially been investigated with
chronic patients to evaluate the performance of its
design and the control algorithm.15 Position and orien-
tation of the robotic platform as well as the output
forces were recorded and evaluated by the physical
therapist.15 It has been demonstrated that the robotic
device and the control algorithm can perform the
desired rehabilitation exercises. Later, Rutgers Ankle
has been evaluated with three children suffering from
cerebral palsy.14 Virtual reality games have been used
along with Rutgers Ankle for 12 weeks of evaluation.
Improvements in gait functions such as ankle kine-
matics, cadence and endurance are claimed to have
been achieved.14
ARBOT and its AAN control scheme have been
evaluated with five healthy subjects.20 The admittance-
based AAN control scheme has proven to be effective,
and the variation in robotic assistance has been
achieved depending upon the level of effort offered by
healthy subjects.20 Impedance control–based AAN
robotic ankle rehabilitation strategy has been evaluated
with 10 healthy subjects.19 The desired performance of
the parallel robot during all four control modes has
been achieved with healthy subjects. It has also been
demonstrated that an increase in robotic compliance
encouraged the healthy subjects to contribute actively
toward the robotic training process.19 Robotic wobble
board–based system has been evaluated with 20 healthy
subjects and one patient.40 Greater stability of ankle
joint has been observed following two weeks of training
with the robotic wobble board along with the golf-
based virtual reality system.40
MecDEAR has been evaluated with healthy subjects
to validate its performance in terms of positioning error
and speed of actuation.16 The results demonstrated the
validity of design and actuations.16 The evaluations of
the platform-based robot have also been carried out
with five healthy subjects.46 Static stiffness, root mean
square tracking error and active stiffness were utilized
to evaluate the performance.46 The desired performance
indices have been achieved during the experimental evo-
lutions with healthy subjects.46
8 Proc IMechE Part H: J Engineering in Medicine 00(0)

Hollander et al.31 and Ward et al.32

Discussion

Jamwal et al.13 and Tsoi and Xie45

Girone et al.15 and Borràs et al.38
Several robotic orthoses and parallel robots have been

Ferris and colleagues8,27,29

developed for the ankle rehabilitation of patients suf-
fering from stoke and SCI (Table 1). Significant
research has been carried out during the last two

Jamwal et al.6,11,25
Rakhodaei et al.43
Bharadwaj et al.30
Blaya and Herr9
decades in the fields of mechanism design, actuation

Erdogan et al.36
Shorter et al.33

Saglia et al.10,20

Karime et al.40

Bucca et al.16
Wang et al.42

Vallés et al.44
and control of robotic ankle orthoses and parallel ankle

Park et al.26
References

Roy et al.5
robots (Table 1). A particular emphasis of the recent
research has been to design the robotic orthoses and
parallel robots mechanisms which can provide natura-

AFO: ankle-foot orthosis; SEA: series elastic actuator; DC: direct current; PMA: pneumatic muscle actuator; ARBOT: ankle rehabilitation robot; PRS: prismatic–revolute–spherical.
listic motion patterns to the ankle-foot complex.
Although this presents significant design challenges, the

Stroke and cerebral

robotic orthoses prototypes such as AnkleBot5,54 and

Healthy subjects

Healthy subjects

Healthy subjects

Healthy subjects
Healthy subjects

Healthy subjects

Healthy subjects
Healthy subjects
Stroke patients
Stroke patients

Stroke patients

Stroke patients

Stroke patient
parallel ankle robots6,25 have tried to address this issue

palsy patients
Experimental

Not available
Not available

Not available
evaluation
effectively.
The mechanism design of parallel ankle rehabilita-
tion robots is particularly challenging since the ankle is
a complex anatomical joint comprising a true ankle
joint and a subtalar joint. Various movements at the

Assist-as-needed (AAN)

Trajectory tracking (TT)

ankle joint are in fact more complex and are the result Table 1. An overview of mechanism, actuation, control strategies and experimental evaluation of ankle rehabilitation robots.
of coupled translation and rotations about the two Control strategy
ankle joints (i.e. ankle and subtalar joints). Most of the

Not available
Not available
ankle robots are designed considering ankle joint as a
spherical one and thereby have issues of kinematic
compatibility. Furthermore, an ankle rehabilitation
AAN
AAN

AAN

AAN

AAN
TT
TT
TT
TT
TT

TT

TT

TT
robot should have an adequate workspace, free from
singularities. The ankle robot must also provide requi-
site forces/torques, in order to carry out intended reha-

Not available
bilitation exercises. Finally, the ankle robot design
Actuated

must be safe to operate and should not be intimidating

Three
Three

Three
DOF

Four

Four
One

One

One

One

One
Two

Two
Two

Two

Two

Two
to the uninformed user.
Selection of actuators plays an important role in the
design and safe human–robot interaction of robotic
Rotary pneumatic

Vibration motors
ankle rehabilitation orthoses and parallel robots.5,6,8
The electromagnetic actuators used in the initial proto- Not available
DC motor
DC motor
DC motor

DC motor

DC motor
DC motor

DC motor
types of robotic ankle rehabilitation orthoses such as
Actuator

actuator

AnkleBot have high end-point impedance (i.e. stiffness)

PMA
PMA

PMA

PMA
type

SEA

SEA

SEA

which is not considered safe for human–robot interac-

tion.6,7,10 SEA and pneumatic actuators have been
developed and utilized in the design of robotic orthoses
freedom (DOFs)

and parallel ankle robots. ARBOT,10 MIT’s AFO9 and

Degrees of

Assist On-Ankle36 have utilized the concept of SEA

whereas Rutgers Ankle has used pneumatic cylinders
Three
Three

Three

Three

Three
Nine
Four
One

One

One

One

One
Two

Two
Two

Two

as actuators. PMA have been used in the design of

Six

University of Michigan’s AFO8 and parallel ankle

rehabilitation robot.6 These actuation methods have
University of Birmingham Parallel Robot

introduced intrinsic compliance in the mechanism of

Arizona State University Ankle Robot

Low-cost 3-PRS parallel manipulator

robotic orthoses and parallel robots which aids in pro-

Parallel ankle rehabilitation robot
Beijing University Parallel Robot

viding safe human–robot interactions as well as helped

Arizona State University AFO

in reducing the overall weight of robotic orthoses.

University of Michigan AFO

Ankle rehabilitation robot

Development of control strategies for these robotic

Robotic wobble board

gait orthoses and parallel robots is also an active area

of research. Trajectory tracking control methods for the
Bio-inspired AFO
MIT’s AnkleBOT

Assist On-Ankle

initial prototypes such as Rutgers Ankle15 and portable

Rutgers Ankle
Portable AFO
System name

powered AFO have33 been considered to be insufficient

MIT’s AFO

MecDEAR

for providing customized robotic training. Several

ARBOT

ANN control strategies have been developed during the

last two decades. Majority of these AAN strategies
Hussain et al.
measure the human–robot interaction for the force/tor-
que sensors and modify the robotic impedance accord-
ingly. However, obtaining the reliable data from force
sensors during the events such as heel strike presents
challenges. Few robotic exoskeletons work on the basis
of finite-state machine algorithms.9 The gait cycle is
divided into a number of phases for the implementation
of finite-state machine–based controllers. These algo-
rithms detect the patients’ intention based on GRFs or
the center of mass displacements and modify the joint
trajectories and required actuator torques accordingly.
However, use of these methods may result in unstable
walking patterns.
Control of robotic orthoses and parallel robots pow-
ered by SEA and PMA present significant challenges
owing to the non-linear and time-varying behavior of
PMA and springs used in the design of SEA. Trajectory
tracking and AAN strategies have been developed for
ARBOT, Assist On-Ankle36 and parallel ankle rehabili-
tation robot,6 but have only been evaluated with few
healthy subjects. Their clinical evaluations still need to
be carried out to establish the therapeutic efficacy.
EMG signals have been used for the proportional con-
trol of University of Michigan’s AFO8 with healthy
subjects, but it poses implementation-related challenges
as the placement of EMG electrodes at the same loca-
tion for each training session is difficult.
The alignment of these robotic orthoses and parallel
robot mechanisms with anatomical ankle joint is also
an emerging area of research. Ankle is a complex ana-
tomical joint, and its alignment presents significant
design challenges. Most of the ankle robots share com-
mon design problem whereby the measured end effec-
tor orientation may not be representative of the actual
foot–shank displacement. This happens due to the fact
that the pivoting point of the ankle robot end effector
does not coincide with the center of rotation of the
ankle joint. A study recently conducted with ALEXII
demonstrates that the knee joint misalignment results
in the significant change of human–robot interaction
forces.55 This may result in the inappropriate applica-
tion of robotic orthoses joint torques to anatomical
joints. Several efforts have been reported in the litera-
ture regarding the development of robotic orthoses for
upper limb rehabilitation which provides better align-
ment of robotic orthosis joints with anatomical
joints.56,57 However, no such design effort has been
reported in the literature for the robotic ankle orthoses
and parallel ankle robots. A preliminary bi-axial model
of the ankle complex58 has been reported in the litera-
ture which may provide better alignment of human
ankle with the robotic orthoses and parallel robots, but
no extensive clinical trials have been carried out. Also
the use of high power/weight ratio SEA and PMA may
help in reducing the relative slippage between the
robotic orthoses joints and anatomical joints, but no
experimental evidence has been reported in the
literature.
9
To summarize, significant improvements in the
mechanism design, actuation and AAN control strate-
gies of robotic ankle rehabilitation orthoses and paral-
lel ankle robots have been reported in the last decade.
Further research needs to be done in the field of design
and actuation to see how the light-weight and intrinsi-
cally compliant robotic orthoses and parallel robots
could be developed which can provide naturalistic
motion patterns with minimum actuator model com-
plexities and mechanical energy losses. Also, the
improved alignment of robotic orthoses and parallel
robots with anatomical joints needs to be investigated
and more emphasis should be given to the mechanism
design of robotic orthoses and parallel robots that can
provide better joint alignment. New AAN training stra-
tegies needed to be developed, and the already existing
AAN strategies should be clinically evaluated to pro-
vide benchmarks in the level of assistance provided to
the neurologically impaired patients. This will aid in
developing a standardized rehabilitation framework for
the robot-assisted ankle rehabilitation.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship and/or publication of this article.
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