1604 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO.
8, AUGUST 2018
A Soft Exosuit for Flexible
Upper-Extremity Rehabilitation
Steven Lessard , Pattawong Pansodtee, Ash Robbins, James M. Trombadore,
Sri Kurniawan, and Mircea Teodorescu
Abstract — For stroke survivors and many other people
with upper-extremity impairment, daily life can be difficult
without properly functioning arms. Some modern physical
therapy exercises focus on rehabilitating people with these
troubles by correcting patients’ perceptions of their own
body to eventually regain complete control and strength
over their arms again. Augmentative wearable robots, such
as the upper-extremity exoskeletons and exosuits, may be
able to assist in this endeavor. A common drawback in many
of these exoskeletons, however, is their inability to conform
to the natural flexibility of the human body without a rigid
base. We have built one such exosuit to address this chal-
lenge: Compliant Robotic Upper-extremity eXosuit (CRUX).
This robot is a compliant, lightweight, multi-DoF, portable
exosuit that affords its wearer the ability to augment them-
selves in many unconventional settings (i.e. outside of a
clinic). These attributes are largely achieved by using a
modified tensegrity design situated according to measured
lines of minimal-extension, where a network of tension
members provide a foundation to apply augmentative forces
via precisely placed power-lines. In this paper, we detail the
design process of CRUX, the report on CRUX’s prototypical
composition, and describe the mimetic control algorithm
used. We also discuss the results of three studies that
illustrate the efficacy of CRUX’s mimetic controller, CRUX’s
flexibility and compliance, and the metabolic cost reduction
when users exercise with assistance from CRUX as opposed
to without. We conclude this paper with a summary of our
findings, potential use cases for this technology, and the
direction of future related work.
Index Terms — Exosuits, human-robot interaction,
medical robotics.
I. I NTRODUCTION
A. Bilateral Therapy for Stroke Survivors
S TROKE affects almost 800, 000 Americans each year
and is the fourth highest cause of death in the US [1].
Although some treatment options and therapy do exist, for
many survivors, stroke permanently inhibits their quality of
Manuscript received November 13, 2017; revised May 7, 2018 and
June 17, 2018; accepted July 5, 2018. Date of publication July 9, 2018;
date of current version August 7, 2018. (Corresponding author:
Steven Lessard.)
S. Lessard, P. Pansodtee, A. Robbins, J. M. Trombadore, and
M. Teodorescu are with the Department of Computer Engineering,
University of California at Santa Cruz, Santa Cruz, CA 95064 USA
(e-mail: slessard@ucsc.edu).
S. Kurniawan is with the Department of Computational Media, Univer-
sity of California at Santa Cruz, Santa Cruz, CA 95064 USA.
Digital Object Identifier 10.1109/TNSRE.2018.2854219
1534-4320 © 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
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life by limiting both their psychological and physical capabil-
ities. Treatments such as Graded Motor Imagery and mirror
therapy have been previously discovered to benefit those
with diminished motor function [2], [3]. These rehabilitative
techniques focus on visual feedback for the user to promote the
regaining and restrengthening of the patient’s arm movements.
This mirror technique can provide therapy for improving a
stroke survivor’s motor system. A technique that creates this
visual demonstration of movement through physical action can
consequently achieve the same desired effect as traditional
manual therapy but with a higher degree of precision immune
to a practitioner’s inherent human error due to the use of a
robotic guide [4], [5]. Therapists can use these strategies as
the primary mode for rehabilitation of a patient or they can
employ them in conjunction with other methods as well.
Wearable robots, such as soft exoskeletons (“exosuits”),
can promote this treatment through the augmentation and
subsequent retraining of the nervous system. The goals of
Graded Motor Imagery and mirror therapy stem from the
combination of moving the physical self along with reward
signals in the brain representing that the action was properly
completed. An exosuit can theoretically meet this need by
augmenting movements that would otherwise be manipulated
by a physical therapist. However, a critical roadblock that
impedes the design of many wearable robots, including these
potential exosuits, is creating a device which conforms to the
nuances of the human body, specifically its hybrid soft-rigid
structure and consequential flexibility and compliance.
B. Bio-Inspired Design
The human musculoskeletal system, through many genera-
tions of evolution, has optimized the structure of arms to excel
at manipulating in a redundant workspace. The aforementioned
evolution has accomplished this goal through the creation of
a hybrid soft-rigid structure. Bones are nested within a tensile
network of muscles, tendons, ligaments, and fascia to create a
compliant body. Tensegrity structures demonstrate this design
philosophy and have been used previously to construct bio-
inspired arms [6]–[9]. Traditional tensegrity structures use
rod-shaped compression elements nested within a network of
cables (tension elements). Each tension member connects the
end points of two rods together. Each end point of a rod
has at least one tension member connected to it and is not
theoretically limited by an upper-bound on the number of
connected tension members. The combination of these two
LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION 1605

Fig. 2. An OpenSim [13] simulation of a biceps curl. These simulations

produced quantitative evidence regarding the antagonistic nature of
many upper-extremity muscles as well as their expected force and
moment outputs as they perform an exercise.

Fig. 1. CRUX: a soft, lightweight (1.3kg), robotic exosuit for

upper-extremity augmentation that does not significantly inhibit the flexi-
bility of its user. This exosuit can be controlled using a modular backplate
to augment one arm according to the pose of the other.

components and the stated rules yields tension-based structural

integrity. In the tensegrity robots such as Lessard et. al’s
manipulators, actuation is generated through the contraction
of tension elements that compose the structure itself. Like-
wise, the human body generates forces and moves itself by
contracting muscles anchored to rigid bones.
At the center of this force generation are antagonistic pairs.
An antagonistic pair is two muscles, one agonist and its
relative antagonist, that pull opposite to one other. When
an agonist muscle contracts and shortens, the corresponding
antagonistic muscle lengthens inversely proportionally. This Fig. 3. An OpenSim [13] simulation of the fiber length and moment of
phenomenon can be quantified by examining the net torque triceps and biceps from a biceps curl shown in Figure 2. The relationship
produced by the muscles about the joint. Agonist and antago- exhibited by these two muscles illustrates an antagonistic duality, where
the activity of one muscle is inversely proportional to the other.
nist muscles regulate this torque with respect to gravity such
that the joint as a whole is stabilized in the reference frame of
the body [10]. As a result, antagonistic muscle pairs can do
directly influence system construction, control algorithms, and
work at a linear rate despite the non-linear properties inherent
potential use cases.
to the muscles themselves [11]. Using the MoBL-ARMS [12]
OpenSim [13] simulation, the antagonist relationship between
the biceps and triceps while executing a biceps curl can be C. Exoskeletons and Exosuits
observed. Figure 2 shows the simulation at three different time The mechanical augmentation of humans has been an area
steps and distinguishes the fibers of the biceps and triceps. of extensive research in the past decade. Passive and quasi-
Figure 3 shows the change in fiber lengths and the moment passive exoskeletons and exosuits have been shown to reduce
required to execute a biceps curl. From these figures, it can workload for users equipped with the device [14], [15]. Back
be observed that the biceps and triceps act inversely to each and posture supporting exoskeletons are supporting indus-
other and in fact form an antagonistic pair, consistent with the trial workers and promoting faster rehabilitation [16], [17].
findings of Solomonow et al. and Gordon and Ghez. The fiber Wearable augmentative gloves are augmenting grasping and
length of the triceps increases as the fiber length of the biceps dexterous movement [18], [19]. Lower-extremity exoskeletons
decreases. The moment about the elbow created by the biceps and exosuits have been developed for gait assistance and
is positive while the moment created by the triceps about the leg augmentation [20], [21]. Upper-extremity exoskeletons
elbow is negative. have been developed for numerous purposes centered around
Both the tensegrity models as well as the antagonistic assisting a user through force generation. Training wearable
muscle pair simulations provide insight on force generation devices, such as MAXFAS, improve users’ gun handling tech-
within humans and how such a mechanism can be applied to nique [22]. Other exoskeletons, such as the (CADEN)-7 [23],
hybrid soft-rigid systems. Specifically, these simulations can provide augmentation for the sake of bilateral rehabilitation

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1606 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018
exercises. These designs and others like them have provided
a foundation upon which other upper-extremity exoskeletons
can be developed. For example, the wearable robots from
Tsagarakis et al. [24] and Galiana et al. [25] provide upper
extremity augmentation through the use of compliant mate-
rials. Additionally, exosuits like that of Lessard et al. [26],
Simpson et al. [27], and O’Neill et al. [28] have minimized
the mass and increased the mobility of exosuits to decrease the
functional overhead required for compliant augmentation in
the upper-extremity. Specifically, the design by Simpson et al.
features a set of straps that anchor a unilateral device against
the torso at the waistline and the chest line of the wearer.
A fabric-based vest is used by ONeill et al. to anchor soft
cruciate linkages to the actuator in the users armpit. Both of
these designs use pneumatic actuation to augment users. The
exosuit by Lessard et al. however, uses a full neoprene jacket
with additional tensile components as a tension-based anchor
on the user’s torso. Although these devices have provided
important advances towards the goal of improved upper-
extremity therapy, they also highlight the need for further
development for new flexible and compliant designs that can
conform to the nonlinear human body while still providing
meaningful augmentation.
To address this need, we have redesigned and upgraded
CRUX (the Compliant Robotic Upper-extremity eXosuit). We
originally created CRUX for relatively simple compliant, light-
weight augmentation of the arms [26]. Now we additionally
introduce the modifications to CRUX that have given it a more
flexible structure and more robust control to achieve more
augmentable actions for users than before.
The remainder of this paper is divided into three sections:
the System Design, the Results and Discussion, and the
Conclusion. In the System Design section, we illustrate the
methodology for designing CRUX which uses motion capture
and subsequent cable mapping that reflects the morphology
motion-captured user. We then introduce the mechanics that
afford CRUX its multi-DoF actuation for greater arm move-
ment. Then we demonstrate an implemented controller that
allows CRUX to mimic arm movement bilaterally, a tech-
nique critical to the aforementioned Graded Motor Imagery
and mirror therapy. In the Results and Discussion section,
we subsequently discuss the quantitative and qualitative results
obtained when a group of participants individually use CRUX
to perform specific exercises and test the capabilities of the
exosuit. These tests cover three specific criteria: the efficacy
of the on-board controller and algorithm, the flexibility and
compliance of the exosuit, and the metabolic impact of the
exosuit. In the final section of the paper, the Conclusion,
we summarize our design, results, and the impact they may
have on future soft wearable robots.
II. S YSTEM D ESIGN
When designing CRUX, we identified our target demo-
graphic as users with single-arm impairment. Single-arm
impairment is a prevalent medical issue and exosuits can
potentially address this need. Additionally, by studying users
with single-arm impairment, particularly stroke survivors,
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we examine one subset of potential CRUX users who may
benefit the most from the exosuit. Users who have single-arm
impairment are likely to benefit from or even have already
undergone Graded Motor Imagery and mirror therapy. Both of
these physical therapy techniques demonstrate an immediate
use case for CRUX. The impaired users we recruited would
therefore be able to provide the most meaningful preliminary
commentary and feedback on the device given that CRUX was
designed for bilateral mimicry (a necessary feature for both
mirror therapy and Graded Motor Imagery). This demographic
of users also typically possessed enough upper-extremity
strength to manually override unwarranted or unsafe actuation
if necessary.
The primary focuses of CRUX necessary to address single-
arm impairment are its features that augment users without
significantly sacrificing wearer mobility and flexibility. These
attributes allow users to wear CRUX, a textile-based robot,
more like clothing than a traditional exoskeleton or other
restrictive wearable robot. As a result, users can theoreti-
cally don and wear CRUX in “unconventional” settings and
environments, such as for highly dexterous and contorting
tasks or simply when at-home. In situations like these, rigid
designs may over-constrain the user, or potentially obstruct
motion that could be accomplished normally. Flexible robots
are also more appealing as wearable devices to users than
rigid robots. Prior studies have shown that intuitive physical
interfaces and comfortable fit are significant factors in assistive
device usability and abandonment [29].
To design an exosuit that achieves these goals, we performed
three steps: motion capture to identify lines of minimal exten-
sion in the upper extremity, deriving a cable map from those
lines, and prototyping the exosuit.
A. Identifying the Lines of Minimal Extension
We define lines of minimal extension as those where the
skin shears the least as the body moves. Previous literature
has discussed using lines of non-extension for the design
of counterpressure suits [30], [31]. We differentiate lines of
minimal extension from lines of non-extension to account for
variations we found between specific test subjects and their
body types when identifying the lines.
To identify these lines, we first performed motion capture
to quantify the surface morphology of the arms (Figure 4A).
We began by selecting a characteristic subject to serve as
a template for CRUX. Although CRUX is primarily designed
to assist users with single-arm impairment, the characteristic
subject we chose was unimpaired. This decision was made for
three reasons: to allow CRUX to fit more users, to be safer,
and to avoid exhausting our limited pool of impaired users.
Unimpaired users tended to be more flexible than their
impaired counterparts and for that reason, a test which uses
a healthier subject for designing a particular cable map will
yield a design safer for others to use. Although future exosuits
may be custom-fit and personalized to one person, we used a
single exosuit for all of our tests. For that reason, we chose
to create a template produced by one, healthy individual for
repeated use.
LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION
Fig. 4. The methodology for designing CRUX required us to identify
and quantify the lines of minimal extension upon the skin using motion
capture (A). In this figure, the elastane fabric is fitted for the elbow and
forearm. A separate garment is used for the shoulder and upper-arm.
From the obtained lines of minimal extension, we determined where to
situate anchored parts of the exosuit and the exact paths to place Bowden
cable tendons (B). A prototype of the design was implemented and tested
on users from relevant demographics (C).
Additionally, tests that require users to fully express their
range of motion through stretching, like that required in the
motion capture experiments, are inherently the most likely to
induce hyperextension and inappropriate muscle strain. For
unimpaired users, this risk is minimal, but impaired users face
a greater likelihood of injury.
By reserving our pool of impaired subjects for the
metabolic tests described in the Results and Discussion
section, we improve the quality and reliability of the results
discussed therein. Stroke survivors with single arm neglect
is a very restricting criterion for recruitment and to ensure
that there were enough impaired users for the aforementioned
augmentation experiment, we reserved their participation for
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1607
TABLE I
M OVEMENTS P ERFORMED D URING M OTION C APTURE
TO I DENTIFY L INES OF M INIMAL E XTENSION
that test only. A greater number of impaired subjects in that
experiment yields more credible findings.
The recruited test subject sported one of two thin elastane
garments equipped with IR-reflective tracking dots. This sub-
ject then performed a series of movements (to eventually be
augmented by the exosuit) in which they stretched the joint
covered by that garment to the fullest extent of their range
of motion. The subject then donned a second garment and
fully expressed their range of motion for the joint represented
by the second garment. The first garment covered the elbow
and forearm and the second garment covered the shoulder and
upper-arm.
Table I details the range of motion of the user during motion
capture. The user performed each listed exercise 5 times with
constant tempo before beginning the next exercise. During
each exercise, the user was told to fully stretch their respective
joint during each movement iteration.
Four cameras which surrounded the user during the stretch-
ing captured the movement in 3D space. From these record-
ings, we identified the parts of the fabric which moved the least
during the test. Parts of the arm which stretched more during
motion capture rendered yellower in the resulting graphic and
parts which stretched less rendered darker. The darkest lines in
Figure 4A are the lines of minimal-extension. As a result, rigid
elements of the exosuit were placed to be as perpendicular to
the yellower lines and as parallel to the darker lines as possible.
We developed CRUX around the subsequently acquired
measurements and found from post-study surveys that most
users found the exosuit to fit well enough to augment them
without major inhibition.
The process to identify the lines of minimal extension on
a body can be repeated for any person. This allows future
exosuits to be trivial to customize in size according to that
particular person’s dimensions and lines of minimal extension.
Any user who has been examined via motion capture can
immediately receive their own personalized map of lines of
minimal extension from which a unique cable mapping and
exosuit structure can be created. This can be done because
when tracked users move while wearing the elastane garments,
a unique map detailing that user’s lines of minimal extension
is produced. These lines of minimal extension are annotated on
separate fabric (in the case of CRUX, a neoprene base-layer)
for eventual construction. One important factor of producing
user-unique maps is ensuring that the elastane garment used
for initial tracking fits and stretches for the user as well as
their potential unique exosuit would. So, if a user requires
a larger or smaller elastane tracking garment, the lines of
minimal extension map fitted for that user should not be
1608 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018

produced on a differently sized base-layer just as one would

not wear ill-fitting clothes.

B. Cable Map
From these aforementioned lines of minimal-extension,
we wanted to identify ideal routes for tension elements to pull
along the body. These tension routes would provide a specific
path for cables to adhere to and pull along when contracted
by a motor. Our priority was developing paths to guide cables
that augmented the largest and most influential muscles and
muscle groups of the upper-extremity (namely, those in the
shoulder, upper arm, and forearm).
To identify these muscles and muscle groups, we consulted
past studies on upper-extremity muscular strength in stroke-
survivors. Ikai and Fukunaga have observed that muscular
cross-sectional area accurately predicts muscle strength [32].
Further principal component analysis and cluster analysis by
Bohannon and Andrews have additionally shown the impact
of stroke-induced paresis on upper-extremity movement in the
upper arm and forearm [33]. Additionally, Motricity Index,
a measure of motor function in muscles, has been found to be
a valid indicator of paretic upper-extremity strength in stroke
survivors [34].
Using these findings, we then isolated relevant arm move-
ments according to motion primitives: movements achievable
in one, unique degree-of-freedom. We specifically chose to
augment humeral rotation (in and out), elbow flexion and
extension, wrist pronation and supination, lateral shoulder
raise, and forward shoulder raise and lower. We chose not to
explicitly augment lateral shoulder lowering as gravity already
provided enough force to achieve this motion when users were
upright.
One issue we noticed that hindered the mobility and pota-
bility of prior upper-extremity exosuit designs was the need
for a structural base. Augmentation of the upper-extremity is
particularly challenging because unlike the lower-extremities
which have a single central bone (the pelvis) and the ground
to support movement, the upper-extremities must rely on sup-
porting augmentation without a clear base. We address this by
constructing a tensegrity-inspired base. In traditional tensegrity
structures, compression elements exist as simple rods and
tension elements exist as simple cables that attach two ends
of two different rods. We diverged from traditional tensegrity
designs and instead used an approach that featured not just
cables along the identified tension routes, but an omni-present
tension element which unites them all by connecting to every
rigid element. This omni-present tension element is an elastic
base which is pre-shaped according to human torso and upper-
extremities, to provide distribute applied forces throughout the
entire structure. For the same reason that tensegrity structures
maintain their constitution when internal forces are applied,
the structural integrity of the exosuit as a whole is preserved
during augmentation. An additional change in the design of
our exosuit from dogmatic tensegrity structures is the use of
non-rod rigid elements. Allowing diversity in the shape of the
exosuit’s rigid elements prevents unnecessary limitations to
what shape the backplate, housing and anchors must conform.
Fig. 5. Power-lines, composed of flexible aramid cable threaded through
segments of rigid Bowden housing, channel power from the motors
to actuate the exosuit. Seven power-lines on each arm dictate user
augmentation by assisting the muscle groups highlighted in Figure 4B.
The combination of tension members (i.e. the aramid cables and the neo-
prene base layer) and compression members (e.g. housing segments)
function similarly to tensegrity structures.
On top of the elastic tensegrity-inspired base layer, cables
are pulled along the described routes (Figure 4B), acting
as tendons in our tension-based augmentation exosuit. These
cables are guided along each arm by anchored segments of
rigid Bowden cable housing. This combination of a cable
and its associated housing is called a power-line (Figure 5).
Since there are seven cables planned for each arm of the
exosuit, there are fourteen power-lines outlined during the
cable mapping process.
Each power-line is at maximum length when the associ-
ated muscle(s) are completely relaxed (i.e. not contracted)
and at minimum length when the associated muscle(s) are
completely contracted. Antagonistic power-lines, like their
muscles, are therefore inversely proportional in length. For
example, a biceps power-line at maximum length implies a
triceps power-line at minimum length since the biceps and
triceps muscles are antagonistic to one another. To further
elucidate the above invariant, if we describe the expressed
length of a power-line as:
L = l + cx (1)
0≤c≤1 (2)
where L is the expressed length of a power-line, l is the
minimum length of the power-line (also written as the sum
of lengths of every tube serially composing the power-line),
c as the percentage of contraction, and x as the length of the
exposed cable when the power-line is at maximum length, then
for any pair of antagonistic power-lines:
c1 + c2 = 1 (3)

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LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION
These cable mappings provide the layout and construction of
the physical prototype subsequently created.
C. Prototype
The parts with which we built CRUX were selected accord-
ing to our hybrid soft-rigid design philosophy. Flexibility and
structural compliance were, therefore, achieved by construct-
ing the exosuit out of mostly compliant materials with rigid
elements strategically placed to interfere minimally.
1) Base Layer: The base layer of CRUX is neoprene and
covers both arms as well as the chest and abdomen. This
neoprene is 2 mm thick on the torso and 1 mm thick around
the arms. Since neoprene is spongy and elastic, users maintain
most of their mobility and the exosuit tends to conform to the
user’s body shape. This conformability promotes a low-profile
for the exosuit as well. Both of these attributes are critical
factors in an exosuit that must tout extreme compliance while
simultaneously maintaining the rigidity necessary to anchor
on-board components and actuation forces.
2) Power-Lines: Each power-line consists of a braided-
aramid cable stretched along one of the tension routes. We
define the cable routes of CRUX as the physical paths of a
power-line along a tension route identified during the motion
capture stage of our system design. The cables in CRUX
are rated to 50 lbs-force (220 N), but other limitations in
the exosuit prevent forces that large from being experienced
by the user regardless. There is never more than one cable
strung through any portion of housing as that would induce
unnecessary friction on the cables inside. For the entirety of
the power-line, the cable is above the neoprene base layer, but
for some portions of the power-line, the cable is additionally
surrounded by Bowden cable housing adhered to the base
layer via neoprene cement. Having Bowden cable housing
along the entire power-line would inhibit the flexibility of the
exosuit at the joints, where the majority of the morphological
changes in the upper-extremity occur. To counteract this,
Bowden cable housing was placed only in segments. The
regions of the power-line without Bowden cable housing are
therefore as flexible as the naked cable. The exact method for
determining the location and length of the segments was an
iterative process. For each identified cable route, we started
with Bowden housing whose length reached from one distal
joint to the next joint proximally. After lightly adhering the
Bowden housing to the base layer, a user donned the prototype
and moved their arms according to the largest achievable range
of motion they could. Until the achievable range of motion
matched the user’s range of motion without the Bowden cable
housing, the Bowden cable housing was slightly trimmed
and the process repeated for every segment of Bowden cable
housing and for every cable route. The exact movements used
to test the range of motion were biceps curls and shoulder
rotations. These exercises were selected since they illustrated
movement according to the outlined motion primitives. The
result of this iterative process is the longest lengths of Bowden
housing to provide necessary rigidity without interfering with
user movement.
3) Back Plate: On the back of the exosuit is a modular
backplate constructed out of thin fiber glass. The backplate
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1609
shown in Figure 4C supports 5 of the 6 motors as well as the
battery and a 32 kB microcontroller. The sixth motor is located
on the shoulder of the augmented arm. Since our impaired
participants all had right-arm impairment, we mounted this
sixth motor above the right shoulder. We found that the
movements augmented by this motor (i.e. pronation and
supination) required less anchorage than other movements
augmented by the exosuit and so we placed this motor directly
on the arm to prevent further crowding on the backplate and
upper-back.
The battery is a three-cell 3500 mAh lithium polymer power
source which provides between 11.1 − 12.6 V and up to 50
A. This powers the equipped brushed DC micromotors, each
of which has a stall torque of 88.3 Nm (125 oz-in) and a gear
ratio of about 1000:1. This arrangement of motors focuses
on augmenting the right arm of the user. A plunger (not
visible in Figure 4) is attached to exosuit for use during semi-
autonomous mimetic control.
An additional joystick controller can be detached from this
back plate for user manual override control of the exosuit.
When the joystick is enabled, the user can manually control
two motors simultaneously. The joystick is programmable
to perform two arbitrary pairs of antagonistic movements
(e.g. biceps/triceps movement and pronation/supination). The
two movement pairs can be reprogrammed quickly using an
external laptop, such as in the case of user testing for multiple
types of arm movement. Whenever more than two movements
were required to be manually controlled by the exosuit,
the joystick-interface was replaced by a laptop connected to
the microcontroller via USB cable.
The on-board microcontroller consists of an Arduino Pro
mini development board with custom designed circuit board
and two stackable motor driver modules. On the circuit board,
motor driver modules are connected via I2C. Additionally,
the microcontroller supports the input from external controllers
(including the aforementioned joystick and plunger-button)
and the IMU network.
4) IMU Network: CRUX’s IMU network is a collection of
four wireless standalone IMU nodes where each node senses
using a 3DOF accelerometer, 3DOF gyroscope, and 3DOF
magnetometer. The sensors on these IMU nodes are Bosch
Sensortec BNO055’s. The manufacturer guarantees that there
is never more than 0.5◦ in alignment error between the internal
gyroscope and the labeled surface on any particular model.
This error falls far below what would be significant for
our application. To avoid gimbal lock, each IMU internally
represents rotations mathematically as quaternions instead of
Euler angles and simply outputs the translated roll, pitch, and
yaw. Because our particular use of these IMUs is limited to a
narrow workspace (i.e. only what an arm can reach), we justify
that the error accumulated through the rounding of floating-
point quaternion angles is insignificant.
The IMU nodes operate on a wireless network so that
they afford the system the capability to monitor (sniff) the
transmitted data within the network without creating any
interruptions or lag.
To minimize the difference between IMU orientation and
upper-extremity orientation, we kept the housing modules as
1610 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018
Fig. 6. The locations of the IMUs on CRUX. The locations of both
the proximal and the distal IMU are the same for both the left arm and the
right arm. Markings on the IMU housing and the exosuit ensured that the
IMUs were installed in the same orientation and position for each use of
the exosuit.
flat as possible. This low-profile keeps the IMUs close to the
surface of the exosuit and consequently, the skin of the user.
The IMUs and their housing are placed on the exosuit such
that the pose data for each arm can be distinguished uniquely.
Two IMU nodes are placed on each arm at the forearm (distal)
and above the biceps (proximal). By placing one IMU on each
forearm and one IMU on each upper arm, the orientation
of both halves of both arms can be continuously tracked
(Figure 6). As a result, knowing the poses of the pair of IMUs
on an arm invariably allows one to mathematically reconstruct
the pose of both halves of the arm. Markings on the neoprene
indicate both the position and the orientation expected of
each IMU attached. These on-suit markings correspond to
matching annotations on the IMU housing boxes. The specific
orientation of these IMUs was checked and corrected each
time the exosuit was used for the sake of consistency. In
our user tests, we oriented the upper arm IMUs such that
the housing box was velcroed on the lateral side and the
forearm IMUs such that the housing box was velcroed on the
dorsal side. A feedback acquisition system is used for the IMU
network via DWM1000 wireless transceiver modules. A prior
version of CRUX used IMUs in a similar fashion to this, but
did not incorporate any explicit attachment guides or housing
that are necessary for the mimetic algorithm.
5) Mimetic Control: Although an exosuit controlled manually
via joystick or laptop can express every possible augmentable
arm movement theoretically afforded by the exosuit, passive
control can reduce mandatory input, making the exosuit easier
to operate. Operational difficulty is an important factor to con-
sider, especially since CRUX is designed to be used by those
who are disabled by upper-extremity impairment. Both the
lack of dexterity and lack of operational experience observed
in many people with upper-limb impairment could prevent an
otherwise qualified user from reaping the rehabilitative benefits
of CRUX. For this reason, a passively controlled mode for
CRUX can lower the necessary level of skill to operate the
exosuit.
The passively controlled mode described in this paper is a
mimetic algorithm. This algorithm synchronizes the position
of one arm to the measured position of the other arm.
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Robot position synchronization is a form of consensus
control used in systems to achieve exponential stability semi-
globally [35], [36]. Since the implemented backplate illus-
trated on CRUX has unilateral actuation, the user’s right arm is
augmented while the left is free to move in the tests described
in this paper. The controller measures the pose of the user’s
left arm and attempts to pull the cables on the right arm to
match that. The measurements of both arms’ poses are sensed
via the IMUs. Two reference points are sensed on each arm
from which the arm’s unique pose can be determined.
Since there are two reference points per arm, a state vector
is defined for the leader and follower: Q l and Q f . These
state vectors describe the locations of the two arms, where
θn , αn , φn denote the yaw, pitch and roll of the reference point
n.
Q l = (θ1 , α1 , φ1 , θ2 , α2 , φ2 ) (4)
Q f = (θ3 , α3 , φ3 , θ4 , α4 , φ4 ) (5)
The user’s leader arm is equipped with a plunger button and
accompanying display LED. When pressed, actuation of the
follower arm is possible based on the state. The follower arm
is moved to mirror the position of the leader arm, such that
Q f becomes equivalent to Q l . However, actuation only occurs
when the threshold signal is high. The threshold is defined as:
Q T h = |Q f − Q l | (6)
and the threshold signal will go high only when:
L ≤ Qt h ≤ H (7)
In our implementation, L = 5◦ and H = 40◦ . This threshold
allows for smoother and more calculated movements of the
slave arm. Although selecting threshold of 40◦ sacrifices finer
adjustments and movements during mimicry than a lower
threshold would, we chose a high threshold to ensure wary
users felt safe and confident when using the exosuit. Concerns
for safety were one of the top reasons potential recruited
participants for the user study were hesitant to try CRUX when
taught about the technology. As a result of the high value, this
threshold also protects against any unintended actuation from
the user or overloading of the motors. As a result, however,
the slave and master arm differ minimally in pose due to the
5◦ lower bound of the threshold signal.
The state machine consists of three states: off, ready, and
mimic (Figure 7). The off state is the initial state and does
not allow the user to activate the suit even if the button is
pressed. In the off state Q l is not within Q t h ; the threshold
signal is low and so the suit cannot be activated. But once
Q l is withing the threshold a transition to the ready state will
occur. In the ready state the suit is waiting to be activated by
the user pressing the button. Once the button is pressed the
state will transition to the mimic state, where the LED will
light up indicating to the user the suit is active and actuation
of the slave arm will occur.
This mimetic controller is built upon a simple closed-loop
feedback system. Leading state is tracked by using the median
of the previous five samples. Although a more complicated
LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION
Fig. 7. The state machine for a safe, mimetic controller. The exosuit
functions only when a significant change in orientation between the two
arms is detected and the safety plunger is pressed by the user.
controller, like a Kalman filter, could yield more accurate state
tracking, we determined that the added overhead and hardware
necessary to support such an algorithm would not be worth
the relatively minor improvements in performance. Added
overhead and hardware further adds mass to the backplate,
and requires more computation time and resources.
6) External Applications: CRUX can additionally be com-
bined with other technology to further enhance user efficacy.
In Figure 4C, one user wears a virtual reality (VR) headset
that allows them to interact with a virtual environment while
CRUX augments their arm movements. Although the only
equipment required to use CRUX is the neoprene jacket with
fixed power-lines and an attachable backplate, adding more
hardware such as the VR headset can yield new capabilities
for users, potentially improving rehabilitation.
7) Safety: Human interfacing robots, especially wearable
devices such as exosuits, require built-in safety measures. We
recognize safety at three levels: the hardware, the software,
and the user instruction.
Mechanical limitations are introduced to the design to
avoid any physical harm due to cables pulling uncomfort-
ably or harmfully. Motors are limited to never pull more than
88.3 N theoretically, as dictated by their maximum torque of
125 oz-in and spool radii of 1.0 cm. Additionally, the backplate
can be immediately detached, as can each battery used by
CRUX in the event of overheating.
Software constraints via the controller are implemented as a
redundant safety to prevent harmful behavior as well. Motors
are limited to 80% power, which provides enough strength to
provide meaningful augmentation while still demonstrating the
capability of the exosuit to support stronger motors safely. The
controller also has checks for extreme discrepancies between
the leader arm and the follower arm. Specifically, any IMU-
sensed angle pair with more than 40 degrees in difference
will stop the motors. IMUs that are inactive for more than
0.5 seconds also disable to exosuit as a whole. As stated in
the state machine, these motors are also push button-activated.
These exact numbers can be adjusted according to the user’s
comfort.
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1611
Lastly, every user of CRUX is given a safety briefing
before they use the robot to explain the functions of the
exosuit and familiarize them with the controls. Users who
acknowledge these capabilities and also confirm that in the
event of an emergency, they would be able to overpower the
exosuit’s theoretical maximum strength limit thus overriding
any dangerous actuation.
III. R ESULTS AND D ISCUSSION
To study the capabilities of CRUX, we tested both the
mimetic control algorithm and the mechanical functionality
of the exosuit when it was worn by users. We have split
this study into three parts: the performance of the mimetic
controller, the achievable flexibility and compliance of the
exosuit, and the metabolic effect of the exosuit when per-
forming an exercise. Since CRUX features six independent
motors, there are countless possible arm movements that can
be augmented when factoring in different permutations and
combinations of motor strengths and timings. Each motor can
be operated in parallel to each other motor which means that
with the appropriate controller, almost every arm movement a
user can be perform can theoretically be augmented. Instead
of showcasing results for every possible movement, we chose
important movements for each test that were indicative of
CRUX’s performance at the most foundational level. The
discussed user evaluations and surveys (both quantitative and
qualitative) however still address all movement the users tested
during their respective trials.
A. Mimetic Control
To illustrate the mimetic capabilities of the exosuit,
we chose to exhibit the exosuit response for two basic
arm movements: lateral arm raises (abduction and adduction,
Figure 8) and biceps curls (Figure 9). These two movements
are motion primitives that demonstrate fundamental upper-
extremity movement. Although these two motion primitives do
not express the full capability of the exosuit or the human arm,
they do illustrate examples of the exosuit performing along
two axes of motion critical to more complex arm exercises.
For example, a physical therapist might attempt to strengthen
these foundational movements through mirror therapy before
a patient attempted more complicated rehabilitative exercises.
After the IMUs were attached to CRUX, users were first
instructed to place their arms at their sides and then lift the
leading arm laterally until their hand was level with their
shoulder, outstretched for the entirety of the motion (Figure 8).
For the biceps curls, the exercise also began with the same
neutral pose as before: arms unbent at the side. The user was
then instructed to curl their leading forearm upwards at the
elbow until their hand came close to the shoulder (Figure 9).
In both exercises, users were instructed to purposefully move
their following arm as little as possible, allowing the mimetic
controller to adjust their arm for them.
As the user performed each exercise, the exosuit measured
and output the roll, pitch, and yaw of the four attached IMUs.
These twelve readings and the plunger input constituted the
control signal of the exosuit.
1612 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018

Fig. 8. A user demonstrates a lateral arm raise with CRUX. The user’s leading arm (left) dictates the movement of their following arm (right). The
following arm, lagging behind the leading arm slightly, updates its position using micromotors installed on the backplate. IMUs on the exosuit provide
sensed orientation for CRUX’s controller.

Fig. 9. A user demonstrates a biceps curl with CRUX. The user’s leading arm (left) dictates the movement of their following arm (right). The following
arm, lagging behind the leading arm slightly, updates its position using micromotors installed on the backplate. IMUs on the exosuit provide sensed
orientation for CRUX’s controller.

Figure 10 illustrates the pitch of two of the four different
IMUs on CRUX as a characteristic user learns to use CRUX
for assisting their left arm while performing a lateral arm
raise and lower (Figure 8). Each pair of plots (labeled T1 ,
T2 , and T3 ) illustrates a 17s time period during which the
user learned a critical lesson indicative of that user’s progress
in mastering CRUX. The time period of 17 seconds was
chosen because it was the shortest time period that concisely
illustrated the highlighted lessons learned by that user. T1 , T2 ,
and T3 occur shortly after one another such that the end of T3
occurs roughly one minute after the start of T1 .
At T1 , the user wears CRUX for the first time. Unsure
of what sensation to expect when augmented, the user sub-
consciously resists movement in their following arm as they
move their leading arm. Realizing their rigidity, the user at
roughly t = 10s overcompensates and consciously forces their
following arm to perfectly mimic the leading arm.
At T2 from t = 2s to t = 6s, the user manually overrides the
exosuit to move their follower arm. The user then immediately
and manually re-corrects their follower arm at t = 6s to
be within the predetermined hysteresis threshold for mimetic
control so they can resume mimetic movement assisted by
the exosuit. The correction performed by the user has to
be done manually as it is beneath the threshold to trigger
mimetic movement (40◦ ). The rule followed by the exosuit
is to apply a force via the motors to move the follower arm
until it reaches the pose of the leader arm (within 5◦ ). This
rule, however, does not engage until there is a difference in
pose by ≤ 40◦ . As previously mentioned, although 40◦ is a
large threshold, it further ensures safety in this prototypical
design and reassured users. By t = 8s, the user has relaxed
their control slightly and can recognize the pulling sensation
of CRUX in their upper-arm (proximally). After a few seconds
of acclimating to the pull along CRUX’s power-lines, the user
demonstrates very shaky augmentation, enough to demonstrate
some degree of control in assisting their following arm.
At T3 , the user demonstrates intuitive mastery of CRUX.
When the user lifts their leading arm, the following arm
mimics the precise movement with only a short delay of
around 1s. The user demonstrates a relatively large range of
operation (around 20◦ in proximal pitch and 60◦ in distal
pitch), which is necessary for many arm movements in mirror
therapy. We note one interesting observation in T3 at t = 12s:
the user’s leading arm rapidly moves (perhaps to scratch their
nose) but the following arm does not mimic the movement.
This discrepancy can be attributed to the built-in safety feature
which prevents unintended movement of the following arm.
In a more serious case with stronger motors and a weaker user,
this movement could accidentally damage the user, so CRUX
correctly intervenes at t = 12s to prevent the movement.
The data in Figure 10 demonstrate the proof-of-concept
that CRUX can augment mimetic movement in users who
have learned to operate the exosuit. After around a minute
of wearing CRUX, the user featured in Figure 10 learned to
operate CRUX at level sufficient to augment arm movements
popular in mirror therapy. Formally measuring device mastery
is challenging, but we can confidently say that every user
tested was able to comfortably operate CRUX within minutes.
Occasionally, users would get momentarily stuck, but after
quick instruction from a study proctor, were able to resume

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LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION
Fig. 10. The pitch of two of the four IMUs on CRUX, measured in
degrees with respect to time (accurate to 0.01◦ ). The three pairs of
plots represent three consecutive time periods (T1 , T2 , and T3 ) of 17s
each where a user operates CRUX. Here, the left arm (orange) leads
the movement of the right arm (blue) of one user during a lateral arm
raise and lateral arm lower according to the state machine outlined in
Figure 7 and the movement described in Figure 8. This figure illustrates
the improvement of a characteristic user in leveraging CRUX to augment
right arm movements from one time period to the next.
operation of the exosuit. Future testing can examine ways to
reduce the learning curve for operating similar exosuits.
B. Flexibility and Compliance
Flexibility and compliance, the two most prominent features
that define exosuits apart from traditional exoskeletons, were
measured by change in user range of motion when CRUX was
worn and when CRUX was not worn.
We selected two arm movements, shoulder circles and
biceps curls, to test the flexibility of CRUX. Although the flex-
ibility of the forearms is not included within these exercises,
we found that these two selected movements demonstrated
CRUX’s structural flexibility as required in both the mimetic
control tests and the metabolic tests. Biceps curls fully express
the flexibility of the elbow joint through one movement while
shoulder circles incorporated both shoulder flexion/extension
movement as well as shoulder abduction/adduction into one
combined movement to express the versatile flexibility of
the shoulder joint. This range in motion was tracked in 3D
via an infrared camera system (the Cave Automatic Virtual
Environment) in order to determine whether CRUX posed
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1613
any constrictions. The CAVE is a motion capture system that
uses points of reference (in this case, reflective dots) attached
to the tracked medium (either a thin elastene sleeve or the
exosuit itself) to record position over time. The cameras
installed within the CAVE for motion capture are manufacturer
guaranteed to provide within 2mm accuracy for tracking,
however accuracy is often within 0.3mm.
To discover the full range of motion achievable of the exo-
suit, we recruited four users who identified as highly-flexible.
For this study, participants did not need to be impaired users
since the study measures mechanical properties inherent to the
exosuit itself and not the target demographic. Additionally,
unimpaired, flexible users provide a more thorough stress test
for CRUX’s flexibility and compliance. These users performed
five iterations of each exercise while wearing reflective track-
ing dots on their arms similar to those in Figure 4A. They
then repeated both sets of exercises while wearing CRUX,
which was also fitted with reflective tracking dots. Surrounding
infrared cameras recorded this movement in three-dimensions
of space.
Because all four users wore the same exosuit (i.e. CRUX)
during this study, none of them perfectly conformed to the
precise dimensions of the exosuit which was designed using
a separate subject. Although in theory this concession could
have created a suboptimal exosuit for the users to wear,
we fortunately found that there was no significant impedance
in user flexibility when wearing this exosuit.
The arm movements observed with and without the exosuit
appear to correspond to one another closely. Although there
is slight mismatch between the red and green trajectories,
this can be attributed to differences in human movement
between trials and is insignificant regardless. We observe a
small discrepancy in biceps curls flexibility which we attribute
to insignificant noise. Most likely, this was probably users
simply stretching their bodies more forcefully without CRUX.
For similar reasons, we see in the shoulder range of motion
plot that users wearing CRUX appear to be more flexible at
times than without CRUX, which is unlikely given that CRUXs
neoprene is objectively more restrictive than the baseline
elastane garment. These results are consistent with our expec-
tations that CRUX will not impede users significantly since
the design process for applying rigid, constrictive elements
to the prototype outlined in Section II iterates until the user
wearing the exosuit confirms that CRUX no longer inhibits
their motion.
Additionally during the metabolic testing (which had thir-
teen recruited users), post-study surveys probed qualitatively
into exosuit flexibility and compliance. Two of the thirteen
users reported that the exosuit slightly inhibited their range
of motion. Both of these users mentioned in their post-study
interviews that they attribute this inhibition to the neoprene
base layer being too tight for their stature. The other eleven
users did not complaint regarding the flexibility or compliance
of the exosuit.
From these findings, we conclude that the structure of
CRUX does not appear to inhibit user movement significantly
enough to impede the movements central to mirror therapy
and upper-extremity rehabilitation.
1614 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018

C. Metabolic Efficacy and User Study

Central to the paradigms of Graded Motor Imagery and

mirror therapy is that the user experiences visual and kinetic
feedback as they perform an exercise [4]. Traditionally, this
reinforcement is physical assistance from the practitioner. For
example, a physical therapist may tell an impaired patient to
lift their arm. As this hypothetical patient attempts to lifts their
arm, the physical therapist uses their own strength to move the
patient’s arm simultaneously. As a result, the user experiences
arm movement for less energy than they exerted, reinforcing
their neurological recovery.
To substitute for this function, CRUX must therefore
mechanically assist the user during the exercise, ideally with-
out any additional metabolic cost. To study the metabolic
reduction provided by CRUX (necessary for the proposed
physical therapy), we measured users’ heart rates as they
performed biceps curls without the exosuit powered on and
then while wearing the exosuit.
To understand the correlation between heart rate and
metabolic expenditure, we consulted a survey paper that dis-
cusses and compares various methods of measuring physical
activity in humans across 63 different studies [37]. One
of the methods to measure physical activity of the body
discussed by Dowd et al. is heart rate, the same metric
tracked in our research examining the metabolic efficiency of
CRUX. Although this paper concedes that heart rate and every
other metric the authors examined are imperfect measures
of true metabolic cost, Dowd et al. still recommend that
researchers should select an objective metric, like heart rate,
over self-reported data for greater accuracy and precision
when conducting studies. Since biceps curls with weights is
a physical activity, we can therefore (relatively) accurately
measure metabolic cost indirectly in adults via heart rate
monitoring. Fig. 11. These plots illustrate the normalized 2D projection of wrists
We chose to demonstrate CRUX’s augmentation on biceps moving through space. The flexibility of a user’s arm is most clearly seen
at the user’s distal portion of the extremity (i.e. the hand and wrist) where
curls for two reasons. First, isolating a single motor’s limits in range of motion are more pronounced. Users’ ranges of motion
metabolic effect on users demonstrates the purpose of the were examined for two main exercises: lateral arm circles and biceps
exosuit most clearly and with the least amount of possible curls. These movements were selected because they exhibit extreme
motion that a person using CRUX may experience. Motion with the
interference. Secondly, we chose biceps curls as an exercise exosuit on or off is portrayed as green and red lines respectively.
explicitly for the reason that discussions with licensed physical
therapists revealed the necessity of strengthening specifically
the biceps muscles during stroke rehabilitation for upper-
extremity neglect due to their prevalence in the majority of of our unimpaired users was 26. Of the 9 impaired users, 7
patients’ day-to-day arm movement. had previously visited a physical therapist. When asked how
We recruited 13 users for our study: 9 who had suffered much they agreed with the statement “My physical therapy
some degree of upper-extremity impairment and 4 who were was helpful.”, all 7 relevant users chose “Agree” or “Strongly
unimpaired and served as a control group. When recruiting Agree” on a five-point Likert scale. Metabolic testing was
impaired users for this study, we used very precise inclu- performed in a lab for 8 participants, and at the homes of the
sion criteria. We requested that users had single-arm weak- remaining 5 participants. All 5 participants who performed a
ness or neglect, but not paralysis. This relatively vague request metabolic test at their home were impaired.
was made to ensure that users who self-selected according Users were instructed to lift a dumbbell that they judged
to this statement to apply for the study were predisposed to would fatigue them after ten repetitions. These measurements
be comfortable with donning CRUX. Additionally, the vague were first taken without CRUX worn by the user. After a
criteria ensure that we do not violate HIPAA laws. Of the five minute break, the user performed the same ten repetitions
impaired users, 5 users were women and 4 users were men. while wearing CRUX (powered on). We found that CRUX
Of the unimpaired users, 1 was a woman and 3 were men. The was able to augment biceps strength in users who wore the
median age of our impaired users was 65 and the median age powered robot (Figure 12, Tables II-III).

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LESSARD et al.: SOFT EXOSUIT FOR FLEXIBLE UPPER-EXTREMITY REHABILITATION
Fig. 12. CRUX’s impact on heart rate for users with an existing
upper-extremity impairment and users without one. For both test groups,
users lifted dumbbell weights via biceps curls. We measured heart rate
as an indication of muscle fatigue and metabolic cost due to the exercise.
For a particular user, we measured their initial heart rate before exercise
(while wearing CRUX, unpowered) and their heart rate after performing
ten repetitions of biceps curls. After a brief rest period, the user per-
formed the same exercise now with mechanical assistance from CRUX.
We again measured both the initial and final heart rates of the users
for the assisted exercises. The data of the new starting and finishing
heart rates are adjacent to the unassisted exercise data for each subject.
Mean and median heart rate increases for impaired/unimpaired and
assisted/unassisted users are presented in Tables II and III.
TABLE II
M EAN H EART R ATE P ERCENT I NCREASES
AFTER E XERCISING
Most users saw less of an increase in heart rate while wear-
ing CRUX than without the exosuit powered. For impaired
users, there was a noticeable improvement when using CRUX:
the mean increase in heart rate normalized as a percentage
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1615
TABLE III
M EDIAN H EART R ATE P ERCENT I NCREASES
A FTER E XERCISING
12.4% without assistance from CRUX and 3.03% with assis-
tance from CRUX and the respective medians are 7.7% and
1.6%. For the unimpaired users, there was not as noticeable
of an improvement when wearing CRUX. We investigated the
phenomenon further and inquired about perceived performance
in the post-study survey. We found that all four users reported
a decrease in effort required to lift the weight when assisted
by the exosuit. Potential anomalies could have been caused
by failing to give these unimpaired users enough rest before
their assisted trials. For two of the unimpaired users, their
starting heart rate for the assisted trial was higher than the
initial unassisted resting heart rate. We also noticed decreases
in performed tempo for all users by their second round of
exercise (i.e. assisted by CRUX). This can be the result of
a user selecting a lifted weight that is too heavy for twenty
lifts, which explains both the decrease in tempo and the
abnormal higher starting heart rates and heart rate increases.
We hypothesize that impaired users may be more reluctant
to select a heavy weight and are thus less likely to reach
confounding levels of fatigue.
We also observe that for some users, there were slight
increases and outliers in heart rate increase. In at least one
case, an impaired user mentioned in their pre-study survey
that they suffered from PTSD, which caused their starting
heart rate and heart rate increases to be significantly greater
than normal. Additionally, some very large increases in heart
rate we contribute to the user selecting a weight too large for
twenty total lifts. As a result, their energy is depleted when
they complete the second round of exercise (i.e. assisted by
CRUX). We think pre-existing factors such as these caused
abnormal spikes in the heart rate increases for users.
Despite some of these observed gaps in the trend, this
overall difference in heart rate increase, especially among
impaired users, is significant because it supports our hypothe-
sis that CRUX can assist users with physical exercises that are
common in upper-extremity physical therapy by reducing the
metabolic cost of performing the exercise. This allows users
to perform more exercises for less energy.
Additionally, when participants in a lab setting were com-
pared against participants at their own homes, we found no
significant change in exosuit efficacy. Users in labs had a
0.5 percentage point average increase in heart rate over users
at their own homes when accounting for both unassisted
and assisted exercise. For this reason, we believed we were
justified in merging the two data sets and looking at the
cumulative results of both.
The results from the post-study surveys are as equally
promising as the heart rate measurements. According to a
five-point Likert scale, 8 impaired users and 3 unimpaired
users said that they “Agree” or “Strongly Agree” that the
1616 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 26, NO. 8, AUGUST 2018
exosuit assisted them with the assigned tasks. The remaining
2 users said that they “Neither Agree nor Disagree” that the
exosuit assisted their assigned movements. No user said that
they would “Disagree” or “Strongly Disagree” that the exosuit
helped them. Of the 7 users who had previously completed
some physical therapy, all 7 agreed or strongly agreed that such
a device would have been useful during their therapy. Multiple
users commented that they did not feel the exosuit weighing
them down during the tests. The most common complaints
when using the exosuit were confusion when operating the
joystick while simultaneously exercising (during the metabolic
test) and overheating while moving around in the exosuit.
These data illustrate that CRUX can satisfy the need
required of an exosuit for Graded Motor Imagery and mirror
therapy: the ability to mechanically assist the user and provide
positive reinforcement.
IV. C ONCLUSIONS
CRUX enables portable, multi-DoF actuation for the upper-
extremity, including both the forearm and the upper arm.
In previous iterations of CRUX, the ability to control the
exosuit akin to Graded Motor Imagery and mirror therapy had
not been included. The current version of CRUX features both
hardware and software upgrades such as the additional frame-
work to better support IMUs and the mimetic algorithm to
implement the new controller. Additionally, we provide studies
and evaluations which provide evidence that CRUX augments
users without inhibiting their flexibility or compliance and can
therefore function as a rehabilitative device.
CRUX augments users with power-lines superimposed on
a flexible base. Along these power-lines, tension forces are
directed through a tensegrity-inspired foundation. This foun-
dation creates a network upon which localized augmentation
can occur, affording CRUX its portability and its compliance.
These considerations are crucial if CRUX is to comply with
the natural flexibility and redundancy possessed by humans
as well as the practical need for wearable devices that can be
transported to out-of-clinic settings.
Through tendon-based Bowden cables, motors supplement
movement in a particular arm (dictated by the modular
backplate attached). We have demonstrated that a mimetic
controller can pull and release these cables to move a user’s
arm according to the position of their opposing arm. This par-
ticular controller has potential applications in fields including
physical therapy where patients are required to perform tedious
and precise mirrored actions for rehabilitation.
Although we have not completed a long-term study mea-
suring the full efficacy of CRUX, data collected from our
studies illustrate that users were immediately able to move
their arms more easily once they learned how to operate CRUX
during their respective tests. Literature in traditional physical
therapy highlights mobility as a key resource in patients’
recovery post-injury/stroke, so we believe that the increase
in arm mobility afforded by CRUX will be an improvement
upon traditional rehabilitation training.
Future designs can extend these results by adding further
degrees of freedom to match the enormous level of redun-
dancy and fluidity expressed by the human musculoskeletal
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system. The difficulty we foresee in these potential designs is
accomplishing this without over-encumbering the user. These
designs must also maintain proper balance when actuating.
Any applied imbalance could contort the user dangerously
with enough force.
Additionally, the control of exosuits requires further study
and examination. In particular, the development of additional
control interfaces, the optimization of the algorithms behind
them, and the user testing to support them all require further
investigation. One particular autonomous control method, pro-
prioception, can yield an exosuit which interprets and reacts
to user intention. This problem is difficult to solve, however,
because people tend to have such diverse kinematics and
redundant workspaces that the decision to preemptively actuate
an exosuit according to a predicted motion is marred with a
high likelihood of actively antagonizing a user’s movement.
Additionally, there is no guarantee that users who don an
exosuit are comfortable with a non-deterministic robot acting
out of their perceived control.
To summarize, CRUX encapsulates flexible and compli-
ant augmentation for the upper extremity with a degree of
capability that allows for tasks such as bilateral mimicry to
be achieved by a user. Future iterations of this exosuit will
hopefully extend these principles and usher in even greater
possibilities for portable, lightweight wearable robots.
ACKNOWLEDGMENT
The authors would like to thank Leonard Norton for pro-
viding advice on the physical therapy movements that were
translated into exosuit supported movements. Additionally,
the authors would like to thank the Cabrillo College Stroke
Center for their assistance with the user studies.
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