Design of a Pediatric Exoskeleton for

Individuals with Neuromuscular Disorders

through Computational Parameter
Optimization

Jessica Zistatsis, Per Lukas Hillerstrom, Lauren Martini, Mackenzie Andrews

BIOEN 485: Computational Bioengineering (Spring 2017), Dr. Wendy Thomas

University of Washington
Abstract

The amount of time a child spends learning to walk is instrumental to developing proper
gait patterns. Children with neurological disorders such as cerebral palsy, spina bifida,
or stroke start walking at a later age and require extensive therapy to improve their
walking ability. An exotendon driven pediatric exoskeleton is being developed as a
passive gait assistance system for these children, but a computational model is needed
to determine how much assistance this device provides in terms of force through the
exotendon with respect to device parameters. A MATLAB model was developed to
describe the force provided by the exoskeleton and optimize the device parameters for
any given child weight and leg length. Optimized parameter sets were determined for
several child weights and leg lengths, and these results were compared with
experimental data from literature. The model was found to produce results that matched
experimental data, and successfully fit the device parameters such that impaired patient
joint moments with exotendon assistance were shown by the model to match the joint
moments of unimpaired patients. This model may be used to inform device design and
assist clinicians when fitting the device to individual children.

Background

Children with neuromuscular disorders such as cerebral palsy (CP) often have walking
disabilities and experience motor delays. These impairments impact roughly 5 out of
every 1000 children born in the US each year (cerebral palsy ~3/1000, spina bifida 1-
10/1000, spinal cord injury ~0.15/1000, pediatric stroke ~1/100,000) [1-4]. Decreased
mobility negatively impacts cognitive development and limits a child’s ability to play and
engage with their peers[5,6]. As such, it is critical that they get walking training and
practice. However, these children get significantly less walking practice than their
typically developing (TD) peers [7] even though they need more practice [8].

Targeted exercises for lower limb muscles increase strength, function, and speed in
children with CP [9-11], yet walking improvements are directly dependent on the amount
of practice and repetition [12]. Additionally, these exercises are labor-intensive[13],
costly, and can be difficult to perform safely [14]. Many of these solutions require
assistance by a trained clinician such as a physical therapist (e.g. body-weight
supported treadmill training and $1M+ robotic systems for in-clinic use). To provide
challenging variability in tasks and environments to generalize learning, practice outside
of therapy is critical [12].
Exoskeletons have been researched as devices to assist walking. Robotic exoskeletons
like Lokomat have been shown successful with adults, but Lefmann et al demonstrated
through a systematic review that robotic exoskeletons have not shown consistent
statistically significant benefits for children [15]. There was no significant difference in
robotic assisted gait training (RAGT) compared to exercise or physiotherapy alone, 8/9
studies on standing showed statistically significant improvements in standing after
RAGT, 6/9 studies on walking showed statistically significant improvements in walking
after RAGT, and 3/8 studies on endurance showed statistically significant improvements
in walking endurance after RAGT [15]. Passive exoskeletons can reduce the metabolic
cost of walking and increase mechanical work performed by muscle fascicles [16].
Collins et al studied a passive ankle exoskeleton on healthy subjects and found that it
produced a torque pattern similar to the biological ankle but lower in magnitude while
reducing the ankle moment initiated by the calf muscles and reducing the calf muscle
activation [16].

Based on this, we propose that a passive hip-knee-ankle exoskeleton could reduce the
energy cost of walking for children with neuromuscular disorders while training these
children with a proper gait pattern outside of therapy. To determine optimal device
design for children and to understand the level of walking assistance provided by the
exoskeleton, a model is needed that relates kinematic data and device parameters to
forces experienced by the exoskeleton.

Previous models for related studies use a graphic based model system in OpenSim.
The movement model for most of the studies found were constructed using a muscle
tendon model created by Delp et al in 1990 [17,18] (43 musculotendon elements) or
Hicks et al in 2007 [19] (92 musculotendon elements). These models took video of
tracking dots as an input, matched the tracking dots to the 3d graphic model, and output
the musculotendon force and joint moment of each group. These were used for
analyzing changes in gait and ground force reactions due to parameters affected by
cerebral palsy as well as gait speed. They found that higher gait speed and increased
level of crouch both significantly increase the level of muscle force required to achieve a
complete swing phase.

None of these models are able to simulate the forces exhibited in an exotendon, only in
the specific geometry of the human leg. One of these models [19] specifically used
children's body sizes and was able to align it with their measured data, and may be
useful for confirming ground based reactions of a new exotendon model for assisting
children to achieve the required muscle force for a complete swing phase. One excel-
based model was found for analyzing exotendon forces [20], and was found accurate
when compared with experimental adult data [21]. This model computes the exotendon
force for four different exotendon designs with inputs of joint kinematics over a gait cycle
and parameters of spring stiffness and hip, knee, and ankle pulley radii. The parameters
are then optimized by minimizing residual joint moments.

This paper aims to address three key questions by developing a parameter optimization
model: (1) How does the force through an exotendon vary with device parameters (such
as pulley radii and spring stiffness) and human factors (gait pattern, mass, leg length)?
(2) How sensitive are the device parameters to child size? (3) How does knowledge of
optimized device parameters influence device manufacturing and clinical
implementation? We hypothesize that the model will be best optimized by varying
spring stiffness and leaving pulley radii constant, which would allow a simple in-clinic
adaptation for a range of children. The model indicated that the exotendon force varies
drastically with spring stiffness alone, but when spring stiffness is constrained, the
exotendon force is mostly dependant on pulley radii. Likewise, spring stiffness is highly
sensitive to child size; however, the ankle and hip pulley radii provide for better force
optimization as child size varies. The outputs of this model will inform design for a
passive pediatric exoskeleton to assist walking in children with neuromuscular
disorders.

Methods

The study was completed by (1) verifying the validity of an existing model for predicting
exotendon force during gait, (2) creating a MATLAB version of this existing model, and
(3) scaling the model for children to optimize exotendon stiffness given device
parameters. In this study, the exotendon originates at the hip, travels around a hip
pulley of specified radius, then travels around a knee pulley of specified radius, then
travels around an ankle pulley of specified radius at which point the tendon is fixed.
There is a passive mechanical spring in series with the exotendon. This system powers
an exoskeleton (Figure 1).

Figure 1: The prototype of a passive

pediatric exoskeleton utilizing an
exotendon and joint pulleys.
VERIFYING EXISTING MODEL MATCHES EXPERIMENTAL DATA

The exotendon model was proposed by van den Bogert [20] to optimize exoskeleton
designs based on residual joint moments. The exotendon force output for a design with
an exotendon running from the hip to the knee to the ankle was experimentally verified
in a patent for an adult exoskeleton [21] when the model parameters were set to those
of the device:

rHip = 66.83 mm
rKnee = 4.78 mm
rAnkle = -47.37 mm
k = 1229.39 N/m
Slack length = -61.51 mm (for the specified spring constant and a 17 lb preload)

The parameter k is the exotendon spring constant, or stiffness. This may be adjusted by
switching out the spring used in the exoskeleton, which is in series with the exotendon.
Each of the three exoskeleton joints has a pulley of adjustable size, where rAnkle,
rKnee and rHip are the radii of these pulleys. A negative radius indicates the tendon
wraps around the posterior side of the joint pulley and a positive radius indicates
wrapping around the anterior side. The slack length is calculated based on k and the
preload, which may be set, as described by:

−𝑝𝑟𝑒𝑙𝑜𝑎𝑑
𝑆𝑙𝑎𝑐𝑘 𝐿𝑒𝑛𝑔𝑡ℎ = (1)
𝑘

With the specified parameters above, the model yields a peak force of 21.2 lb (Figure
2). This matches well with the experimental results of the maximum exotendon forces
achieved with an unimpaired adult walking in the exoskeleton for several steps (Figure
3) [21].
 (a)

(b)
Figure 2: van den Bogert model prediction of tendon force for a preload of 17lb, where the twin is the
exotendon on the opposite leg. Figure a shows the force in English units and Figure b shows the force in
metric units.
 Figure 3: Experimental tendon force for a preload of 17-20lb [21].

VERIFYING ACCURACY OF MATLAB MODEL

In order to adapt the van den Bogert model to MATLAB (See Appendix), the joint angle
and position data from the healthy patient used to generate Figure 2 were imported. The
angle data for the hip, knee and ankle was then extracted from the imported data as
aHip, aKnee, and aAnkle, respectively. The parameter values for the device (rHip,
rKnee, rAnkle, k, and Slack length) were declared. The parameter values and imported
data were used to calculate the exotendon force (Fexotendon) using the same equation as
the van den Bogert model (eq. 2).

𝐹𝑒𝑥𝑜𝑡𝑒𝑛𝑑𝑜𝑛 = 𝑘 ∗ [(𝑎𝐴𝑛𝑘𝑙𝑒) ∗ (𝑟𝐴𝑛𝑘𝑙𝑒) + (𝑎𝐾𝑛𝑒𝑒) ∗ (𝑟𝐾𝑛𝑒𝑒) + (𝑎𝐻𝑖𝑝) ∗ (𝑟𝐻𝑖𝑝) +

(−𝑆𝑙𝑎𝑐𝑘 𝑙𝑒𝑛𝑔𝑡ℎ)] (2)

The exotendon force was plotted against time as a percentage of gait cycle, as was
done in the van den Bogert model (Figure 4). Comparison to the van den Bogert model
(Figure 2a) verifies the mathematical accuracy of the MATLAB adaptation.
 Figure 4: MATLAB adaptation of van den Bogert model for a preload of 17lb.

To verify that the model behaves as expected for variable tendon stiffnesses, the k
value was varied from 500 N/m to 1500 N/m. A plot of the maximum and minimum
exotendon forces for each k value was generated (Figure 5). These results show that as
k is increased, the exotendon forces also increase as we would expect based on the
linear relationship between stiffness and force with a constant displacement.

Figure 5: Demonstration that the MATLAB model predicts increasing exotendon force with increasing
exotendon stiffness.
OPTIMIZING THE MODEL FOR CHILDREN

To then translate this model for children with walking impairments, a minimization was
performed on the residuals over the gait cycle, where the the residual is defined as the
difference between an unimpaired child’s joint moments and the sum of the exotendon’s
joint moments with the impaired child’s joint moments (eq. 3). The optimized parameter
of interest is the spring stiffness (k).

R = normative joint moments - (impaired joint moments + exotendon joint moments)

The residual moment for each joint is defined as:

𝑅𝑗 = 𝑀𝑗−𝑛𝑜𝑟𝑚 − (𝑀𝑗−𝑖𝑚𝑝 + 𝑀𝑗−𝑒𝑥𝑜 ) (3)

The moment created by the tendon at each joint, at each time point, was calculated by
multiplying the exotendon force at that gait position by the moment arm, which is that
joint’s pulley radius (eq. 4). The force applied by the tendon was calculated by
multiplying the spring stiffness of the tendon by the difference in tendon length at that
position compared to its unstressed length (eq. 2).

𝑀𝑗−𝑒𝑥𝑜 = 𝐹𝑒𝑥𝑜𝑒𝑛𝑑𝑜𝑛 ∗ 𝑟𝑗 (4)

To calculate the normative joint moments for the child, the adult normative moment data
available was nondimensionalized by dividing by the quantity of the adult’s body weight
times their leg length. It was then scaled to the child of interest by multiplying by the
quantity of the child’s body weight times their leg length (eq. 5). This provides a reliable
estimation of normative pediatric joint moments in lieu of gathered data.

𝑐ℎ𝑖𝑙𝑑 𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡∗𝑙𝑒𝑔 𝑙𝑒𝑛𝑔𝑡ℎ

𝑁𝑜𝑟𝑚 𝑐ℎ𝑖𝑙𝑑 𝑚𝑜𝑚𝑒𝑛𝑡 = 𝑛𝑜𝑟𝑚 𝑎𝑑𝑢𝑙𝑡 𝑚𝑜𝑚𝑒𝑛𝑡 ∗ (5)
𝑎𝑑𝑢𝑙𝑡 𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 ∗ 𝑙𝑒𝑔 𝑙𝑒𝑛𝑔𝑡ℎ

To calculate an impaired child's joint moments throughout the gait cycle, we used a ratio
of the maximum joint moment for a normal kid to that of a barefoot child with cerebral
palsy as presented by Lam et al [22]. This ratio was then multiplied by the normative
child moments as computed in eq. 5. We assume that the clinician fitting the
exoskeleton has knowledge of the child’s hip, knee, and ankle moments either from
motion capture or low cost sensors [23]. We understand that this is not a true model of
the impaired child's gait cycle as impaired gait does not follow normal joint angles, but
this provides an estimation of joint moments in lieu of impaired gait data, and will be
replaced with gathered data when it becomes available.
These joint moments are over the course of the gait cycle. For purposes of this
preliminary analysis, we assume that the joint angles of the impaired child are the same
as an unimpaired child, such that the only difference between the impaired and
unimpaired child is the muscle force. Once data is obtained for impaired gait, it will be
incorporated into the optimization. We should note that gait patterns vary quite
drastically within impaired populations, so there is not a typical gait pattern for children
with cerebral palsy.

VERIFICATION OF MODEL

To verify that our model accurately scales the adult data to produce a representative
child data set, we used the weight and leg length for a 95th percentile 6-year-old child to
scale the normative adult data. Figure 6 shows a plot of the normative adult moments
compared to the scaled child moments. The scaled child moments generated by the
model match the scaled child moments predicted by the Excel model (Figure 7).

Figure 6: Demonstration that the MATLAB model accurately scales the normative adult moments to child
moments. Adult values used: weight = 70 kg, leg length = 0.9 m. Child values used: weight = 27 kg, leg
length = 0.5588 m.
Figure 7: Child joint moments scaled from adult normative values as predicted by the Excel model. Adult
values used: weight = 70 kg, leg length = 0.9 m. Child values used: weight = 27 kg, leg length = 0.5588m.

The model’s scalability was verified by using a ratio of 0.5 for each joint. Figure 8
demonstrates that our model correctly predicts impaired joint moments that are 50% of
the normative child moments.

Figure 8: The model correctly predicts impaired pediatric joint moments that are scaled to to 50% of
normative pediatric joint moments.
Once model scalability was verified, we verified the optimization outputs. First, we
expect that if an unimpaired person was walking in the exoskeleton, the exotendon
should not provide any assistance. Using normative adult data and adult device
parameters, we set Mj-imp = Mj-norm with the ankle joint as an example. As expected, the
model indicates that the exotendon provides no assistance in terms of joint moments
(Figure 9). Since no assistance from the exotendon is required, the parameter
optimization resulted in a spring constant and preload near zero, making the exotendon
moment near zero as well. This verification was repeated with pediatric device
parameters (Figure 10).

Figure 9: The exotendon provides no joint moment when the adult individual has normal joint moments
(i.e., needs no assistance from the exotendon). The plot above shows the ankle moment as an example,
but all the joint moments display zero exotendon assistance in this scenario.
Figure 10: The exotendon provides no joint moment when the child has normal joint moments (i.e. needs
no assistance from the exotendon). The plot above shows the ankle moment as an example, but all the
joint moments display zero exotendon assistance in this scenario.

Again using pediatric impaired moments as a 0.5 ratio of pediatric normative joint
moments, the model was tested for fitting all parameters (k, preload, slackLength,
rAnkle, rKnee, rHip). Figure 11 demonstrates illustrates the model is underfit, but
provides a reasonably reliable estimation of the exotendon moment, where the sum of
the exotendon moment and the impaired moment (dashed line) give a reasonably
accurate fit to the peak normative moment (solid blue line).
 Figure 11: Fitting the model with five parameters yields a reasonably accurate estimation of the
exotendon joint moment. The ankle moment is shown as an example, but the same level of certainty is
obtained for the knee and hip moments. The sum of the parameter-fit exotendon moment (red) and the
impaired child’s joint moment (green) gives a close fit to the goal of a normative pediatric joint moment
(blue).

Results

A MATLAB model was created to predict the exotendon force in a lower extremity
exoskeleton during gait cycle by optimizing device parameters such as joint radii,
exotendon stiffness and exotendon pre-load to approximate a normative gait when
applied to an impaired gait cycle. The model was verified by using a normative gait
scaled at 50% as the impaired model to confirm operation, then applied to three
impaired gait models to optimize exotendon parameters.

Three simulations were run for children with cerebral palsy. The first was for a 27 kg
child with 0.5588 m leg length (Figure 12), the second was for a 18 kg child with 0.4400
m leg length (Figure 13), and the third was for a 12 kg child with a 0.3302 m leg length
(Figure 14). These variable values were chosen such that the manufactured
exoskeleton could be adjustable in size for 5th percentile three year olds (the third
simulation) to 95th percentile six year olds (the first simulation). For all simulations, the
impaired joint moment ratios were specified according to the ratios found by Lam et al
as described in the methods [22].
Figure 12: Optimized exotendon moments (stars) for each joint moment for a 27kg child with cerebral
palsy with impaired joint moments (dashed) compared to normative pediatric joint moments (solid).

Figure 13: Optimized exotendon moments (stars) for each joint moment for an 18 kg child with cerebral
palsy with impaired joint moments (dashed) compared to normative pediatric joint moments (solid).
 Figure 14: Optimized exotendon moments (stars) for each joint moment for a 12kg child with cerebral
palsy with impaired joint moments (dashed) compared to normative pediatric joint moments (solid).

Each of these simulations illustrate that when a specific ratio of impaired to normal gait
are applied to a normal gait pattern to create an impaired gait pattern, and child leg
length and weight are varied in the model, the model defines an exotendon that adds to
the impaired gait to produce the desired results, namely a normal gait pattern.

As the child increases in size, the spring constant remains nearly constant, but the
optimized device parameters increase in magnitude (Table 1). As these optimized
parameters increase in magnitude, the maximum force through the exotendon
increases.
Table 1: Optimized parameter values found by the model for the three child size models shown in Figures
12-14.

Child Size Estimated Device Parameters

Variables

Child Child Spring Preload Slack Ankle Knee Hip Max

Weight Leg Constant Length Pulley Pulley Pulley Tendon
Length Radius Radius Radius Force
(kg) (N/m) (N) (mm) (mm) (mm) (mm) (N)
(m)

27 0.5588 951.64 32.89 -34.56 -82.47 1.71 67.33 58.51

18 0.4400 951.17 23.82 -25.05 -59.76 1.24 48.79 40.65

12 0.3302 950.52 16.86 -17.72 -42.29 0.88 34.52 33.91

Using these optimized parameters, we find that the exotendon experiences a maximum
force of 58.51N for a 27kg child (Figure 15).

Figure 15: The force from the exotendon over the course of one gait cycle. Child weight was 27 kg, and
child leg length was 0.5588 m. All parameters have been optimized. Compare with Figure 4.

To validate these results experimentally, we would perform a clinical trial or series of

case studies with children ages three to six years old. Their mass and leg lengths must
fit between 5th percentile three year olds (12 kg, 0.3302m) and 95th percentile six year
olds (27 kg, 0.5588m). A set of reflective markers would be placed on bony landmarks
according to a Helen-Hayes marker set. The subjects will walk across a force plate
during the motion capture so that ground reaction forces can be monitored. A series of
inverse dynamics calculations using the joint angles and ground reaction forces will
indicate the joint moments throughout the gait cycle for the subjects. These inverse
dynamics calculations are automatically generated with the motion capture software.
Each subject’s unique gait cycle, mass, leg length, and joint moments (plugged into M imp
in eq. 2) will then be passed into the model.

The model will optimize device parameters (k, preload, rAnkle, rKnee, rHip). An
exoskeleton will be built for each subject with these optimized parameters and they will
repeat the motion capture procedures. A force gage in series with the exotendon will
experimentally measure its force throughout the gait cycle and accelerometers will be
placed at each joint so that the exotendon’s joint moments may be computed. Finally,
the subject’s joint moments can be added with the exoskeleton joint moments at each
point in the gait cycle. The model is validated if this sum is within a defined error
tolerance of the predicted sum from the model.

A series of parameter tests was used to provide an increased understanding of how

device functionality is dependant on device parameters. To determine the effect of
various parameter values on the maximum exotendon force achieved, we varied one
parameter value at a time while holding the others constant at their optimized values for
a particular child weight and leg length.

Child weight was set to 27 kg and child leg length was set to 0.5588 m. Then the plots
in Figure 16 were generated by iterating over a range of values for each parameter and
calculating the exotendon force for each iteration.
 Figure 16: Exotendon force dependence on 5 parameter values (spring constant, preload, ankle pulley
radius, knee pulley radius, and hip pulley radius). Negative pulley radii indicate that the tendon wraps
around the posterior side of the pulley.

Thus, the force through the exotendon varies quite drastically depending on which
parameter is changed. For the ankle pulley, the force decreases as the radius
decreases when the tendon is wrapped posteriorally and increases as the radius
increases when wrapped anteriorally. There is a more shallow rate of force increase
than rate of force decrease. The change in hip pulley radius has a similar effect on force
as the ankle pulley radius, except the hip demonstrates a much lower rate of positive
force change. Force always increases with a knee radius increase. Since the knee is a
central fix point for the exotendon, moving the knee from back to front essentially
stretches the spring which increases the exotendon force.

To understand how sensitive device parameters are to child size, each parameter was
plotted against a range of weight (0 - 20.0kg) and leg length (0 - 1.0m), with all other
parameters held constant. The results were plotted separately for each parameter, and
the surface plots for spring stiffness and preload have been included in Figures 17 and
18. Figure 19 shows these plots for the pulley radii. The spring stiffness flatlines at
1229.39 N/m based on the maximum constraint given to this parameter in the code, as
it is the stiffness used for adult exoskeletons and would be unreasonably high for
children. Spring stiffness increases rapidly as the child grows (Figure 17) while preload
increases slowly (Figure 18).

For the pulley radii sensitivities, the optimal ankle pulley radius decreased with
increasing child weight and leg length, while the optimal knee and hip pulley radii
increased. This can be seen in the slopes of the surface plots in Figure 19.

Figure 17: Sensitivity of spring stiffness with respect to child weight and child leg length.
Figure 18: Sensitivity of preload with respect to both child weight and child leg length.
Figure 19: Sensitivities of the three pulley radii (top left: ankle, top right: knee, bottom: hip) to variation in
child weight and child leg length.

Thus, optimal spring stiffness is extremely sensitive to changes in child size and optimal
preload is moderately sensitive. Of the joint pulleys, the ankle radius is most sensitive to
child size (100 mm range), closely followed by the hip pulley radius (80mm range). The
knee pulley radius is hardly sensitive to changes in child size. This corresponds to the
approximately zero knee moment provided by the exotendon in Figures 12-14.

These results indicate that while spring stiffness alone is highly sensitive to child size,
the optimal stiffness when optimized with the other five parameters is actually
approximately constant with child size (Table 1). Thus, when designing the exoskeleton,
it is optimal to have a constant spring stiffness with variable joint pulley radii.
Discussion

Children with neuromuscular disorders such as cerebral palsy often benefit from
assistive walking devices to gain muscular strength and coordination. Passive
exoskeletons are one option to reduce the metabolic cost and improve muscle
recruitment required for walking. We developed a computational model to predict the
force requirements of a passive, single leg, hip-knee-ankle exotendon design to assist
children with a known amount of muscular impairment. Our model also estimates the
optimized device parameters needed to achieve the residual force requirement and
provides an overall picture of how device functionality depends on child size and device
parameters.

Using scaling factors, we were able to appropriately adapt the adult data set from the
van den Bogert model [20] to model the joint moments of a child. Our scaled model
prediction of child joint moments match normative values found in a study by Helene
Nikolajsen et al. on musculoskeletal disorders in children [24]. Using the generated
normative child moments, we estimated impaired child joint moments by individually
scaling the peak normative hip, knee, and ankle moments by literature values for
impaired child joint moments [22]. Generating these sample normative and impaired
child data sets allowed us to build our model as a basis for pediatric implementation of
the device.

Using the generated child data sets, we performed parameter optimization to achieve
an exotendon force equal to the difference of muscle force between a normative and
impaired child. An unexpected result was that the optimized tendon stiffness remained
relatively constant regardless of the child size or force difference between the normal
and impaired child. We hypothesize that this result was due to the fact that changing the
exotendon spring constant will affect all joint moments equally. The majority of the force
residuals were minimized by changing the ankle and hip pulley radii. Our results
indicate that, for every child size, the estimated exotendon knee moments are nearly
zero and the optimized knee pulley radius is very small compared to the ankle and hip
pulley radii (Figures 12-14, Table 1). From a functionality standpoint, this result
suggests that the knee is a passive joint in the exotendon device and has minimal
contribution to the joint moment generated by the device. From a manufacturing
standpoint, this means that the knee pulley radius may remain constant while the hip
and ankle pulleys would benefit from having variable radii capabilities for simple, in-
clinic tuning of the device.

To further the application and robustness of this model for predicting exotendon force
and device design, we intend to (1) gather a dataset of impaired pediatric joint angles
and joint moments and (2) revise the model to handle a wide variety of impaired gait
patterns. The model is currently based on the low level of certainty assumption that
children with cerebral palsy walk with normative joint angles, but can easily become
high level of certainty by importing child-specific impaired joint angles gathered
experimentally as described in the results section. This experiment would also result in
child-specific impaired joint moments that would replace the assumption that impaired
joint moments are a consistent ratio of the normative pediatric joint moments throughout
the gait cycle. The second major simplifying assumption was that children with cerebral
palsy will always have lower muscle forces than typically developing children. The
residual moments equation (eq. 3) only works for this assumption. However, cerebral
palsy influences a wide variety of gait patterns and muscle impairments, so many
children with cerebral palsy could have muscle forces higher than normative pediatric
muscle forces due to muscle stiffness. We intend to expand our optimization function to
accommodate lower than normal and higher than normal impaired muscle force inputs.
Additionally, to obtain the greatest ease of use in the clinic, we should weight the
optimization of certain parameters higher than other parameters. For instance, it is
easier for a clinician to adjust the spring stiffness by using a variable stiffness spring or
swapping out springs than it is to substitute joint pulley radii. Thus, we would penalize
the model for changing radii to encourage greater change in the spring stiffness
optimization. Finally, we would incorporate a function that steps forward in time, such as
an ordinary differential equation, taking into account the assistance provided by the
exotendon in the previous step when optimizing for the level of assistance in the current
step.

Table 2 demonstrates a relation between the child's size and the optimized values for
pulley size and preload. By using one child as a baseline, we created an equation that
predicts optimized parameters directly from the child's size. The fractional change from
a baseline for each parameter was calculated by taking the difference between the
baseline value and the value of the run being calculated, then dividing by the baseline
value.

𝐵𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑝𝑎𝑟𝑎𝑚𝑒𝑡𝑒𝑟 − 𝐶ℎ𝑖𝑙𝑑′𝑠 𝑜𝑝𝑡𝑚𝑖𝑧𝑒𝑑 𝑝𝑎𝑟𝑎𝑚𝑒𝑡𝑒𝑟

𝐹𝑟𝑎𝑐𝑡𝑖𝑜𝑛𝑎𝑙 𝑐ℎ𝑎𝑛𝑔𝑒 = (6)
𝐵𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑝𝑎𝑟𝑎𝑚𝑒𝑡𝑒𝑟

The chart of these values shows a relation between the fractional changes of the pulley
radii and preload, and the average of the fractional changes of leg length and child
weight (values in bold). The equation relating these parameters to the child size is of the
form below. Using a chosen, optimized baseline model, a clinician can optimize each
parameter by inputting their patient’s Weight and Leg Length.
 𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑤𝑒𝑖𝑔ℎ𝑡 − 𝑊𝑒𝑖𝑔ℎ𝑡
𝑂𝑝𝑡𝑖𝑚𝑖𝑧𝑒𝑑 𝑝𝑎𝑟𝑎𝑚𝑒𝑡𝑒𝑟 ≈ (𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑝𝑎𝑟𝑎𝑚𝑒𝑡𝑒𝑟 𝑣𝑎𝑙𝑢𝑒) − [1 − +
2∗(𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑤𝑒𝑖𝑔ℎ𝑡)
𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑙𝑒𝑔 𝑙𝑒𝑛𝑔𝑡ℎ − 𝐿𝑒𝑔 𝐿𝑒𝑛𝑔𝑡ℎ
] (7)
2∗(𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑙𝑒𝑔 𝑙𝑒𝑛𝑔𝑡ℎ)

Eq. 7 provides an estimate of the optimized device values, within the given range of
child size variables, with a maximum fractional error for each parameter of 0.506% (the
largest parameter error seen in the last two rows of Table 2).

Table 2: Identifying fractional changes between child size and optimized parameters.

If we can create an average impaired gait cycle from future gathered data, this relation
may allow us to clinically estimate device parameters using only the child’s weight and
leg length. This would be extremely valuable to a clinician, as they would not need to be
trained in the operation of the model, but could simply apply the equations to fit an
exotendon device to their patient.

The accuracy of this equation would need to be tested with more child models to
increase the level of certainty of its application, and would need the parameter
constants and fractional error re-calculated once impaired gait data or a weighting
scheme is applied to the model, to determine if it can still provide a usable estimation.
This equation could be improved by using the impaired gait cycle of a median child size
applied to the model as a baseline rather than the upper extreme as is used here.

Conclusion

After successfully adapting the existing van den Bogert model [20] into MATLAB and
scaling the model to fit pediatric parameters, we explored our proposed aims through
parameter optimization and sensitivity analysis. Our primary finding was that the force
contribution from the exotendon is highly dependant on spring stiffness; however, when
the spring stiffness is constrained by adult parameter values, adjusting the ankle and
hip pulley radii provide for a better gait cycle optimization. Additionally, our model
suggested that the knee pulley radii has little to no effect on the exotendon force and is
minimally sensitive to child size variables. These results could suggest an exotendon
design with variable radii hip and ankle pulleys; however, a more in-depth
manufacturing feasibility analysis would infer the most optimal design parameters. From
our sensitivity analysis, we found an interesting correlation between child size and
optimized parameter values which could allow for a streamlined in-clinic device
optimization from basic patient measurements. This proposed correlation would need
further analysis and testing to confirm its validity. With further analysis, this model could
aid in designing a pediatric exotendon to assist children with neuromuscular disorders
develop a normal walking gait.

Acknowledgements

We would like to acknowledge Dr. Wendy Thomas and Leandra Brettner for their
guidance, assistance, and helpful suggestions throughout this project. We would also
like to acknowledge Dr. Kat Steele for sharing her knowledge on the walking dynamics
associated with cerebral palsy.

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Appendix: MATLAB Code

function optimized = ExotendonModel_function_all(child_weight, child_leg_length)

%Exotendon
%Jessica Zistatsis, Mackenzie Andrews, Lauren Martini,Per Luke
% See below for objective function

% CLEAR, CLOSE
close all;

% ------------------------------------ %

% For testing:
% child_weight = 27 kg
% child_leg_length = 0.5588 m

% LOAD VAN DEN BOGERT DATA

global jointAngles_And_Moments; global time; global angleHip;
global angleKnee; global angleAnkle;

jointAngles_And_Moments = xlsread('Adult Kinematic Data');

time = jointAngles_And_Moments(:,1);
angleHip = jointAngles_And_Moments(:,4);
angleKnee = jointAngles_And_Moments(:,3);
angleAnkle = jointAngles_And_Moments(:,2);

% Make parameters global so the objective function can

% use them as well
global k; global rHip; global rKnee; global rAnkle;
global preload; global lSlack;

% ADULT PARAMETERS
% k = 1229.39; %N/m
% rHip = 66.83; %mm
% rKnee = 4.78; %mm
% rAnkle = -47.37; %mm
% preload = 75.6198; % N

% KID PARAMETERS:
k = 950; % N/m
rHip = 34.0; % mm
rKnee = 4.77; % mm
rAnkle = -26.93; % m
preload = 75.6198/2; % N
lSlack = ((-preload./k)*1000); % mm

% ------------------------------------ %

% MOMENT DIFFERENCE OPTIMIZATION

% Parameter estimation

% Guesses
guesses = [k preload rAnkle rKnee rHip]; % Initial guesses

% fminsearch options
opt = optimset('MaxFunEvals', 2000, 'MaxIter', 2000);

% Bounds on parameters for children

ub = [1229.39, 66.7233, 0, inf, inf];
lb = [0, 0, -inf, -inf, -inf];

[estimates, J] = fmincon(@exotendon_obj_k, guesses, [], [], [], [], ...

lb, ub, [], opt, child_weight, child_leg_length);

% Optimized force plot using parameter esitmates

opt_k = estimates(1);
opt_preload = estimates(2);
opt_rAnkle = estimates(3);
opt_rKnee = estimates(4);
opt_rHip = estimates(5);

opt_lSlack = ((-opt_preload./opt_k)*1000);

% Re-calculate force with optimized parameters

opt_Force = -opt_k.*((opt_rHip.*angleHip+opt_rKnee.*angleKnee+ ...
opt_rAnkle.*angleAnkle).*(pi/180)+opt_lSlack)./1000;

% Export optimized values

optimized = [opt_k opt_preload opt_rAnkle opt_rKnee ...
opt_rHip opt_lSlack opt_Force];

% ----------------------------------------------------------- %

% OBJECTIVE FUNCTION

function [J, res] = exotendon_obj_k(guesses, child_weight, child_leg_length)

global jointAngles_And_Moments; global angleHip; global time;

global angleKnee; global angleAnkle;

% ---------------------------------------- %

% EXOTENDON MOMENT

k = guesses(1);
preload = guesses(2);
rAnkle = guesses(3);
rKnee = guesses(4);
rHip = guesses(5);

% ADULT PARAMETERS:
% rHip = 66.83; %mm
% rKnee = 4.78; %mm
% rAnkle = -47.37; %mm

% % KID PARAMETERS:
% rHip = 34.0; % mm
% rKnee = 4.77; % mm
% rAnkle = -26.93; % m
lSlack = ((-preload./k)*1000); % mm

Force = -k.*((rHip.*angleHip+rKnee.*angleKnee+rAnkle.*angleAnkle)...
.*(pi/180)+lSlack)./1000;

exotendon_ankle_mom = (rAnkle.*Force)./1000;
exotendon_knee_mom = (rKnee.*Force)./1000;
exotendon_hip_mom = (rHip.*Force)./1000;
exotendon_mom = [exotendon_ankle_mom exotendon_knee_mom exotendon_hip_mom];

% ----------------------------------------- %

% EXTRACT NORMATIVE JOINT MOMENTS FROM DATA

norm_ankle_mom = jointAngles_And_Moments(:,8);
norm_knee_mom = jointAngles_And_Moments(:,9);
norm_hip_mom = jointAngles_And_Moments(:,10);
norm_adult_mom = [norm_ankle_mom norm_knee_mom norm_hip_mom];

% Average adult values for scaling to get child normative values

adult_weight = 70; % kg
adult_leg_length = 0.9; % m

% Percent of normative moments applied by kid

kid_percent = child_weight*child_leg_length / (adult_weight*adult_leg_length);

% For children:
normative_mom = norm_adult_mom .* kid_percent;

% Ratios from Lam, W.K., et al. 2004

norm_imp_ratio_ankle = 0.639;
norm_imp_ratio_knee = 0.484;
norm_imp_ratio_hip = 0.526;

% Determine the impaired child moments by scaling the normative

impaired_mom = [norm_imp_ratio_ankle.*normative_mom(:,1) ...
norm_imp_ratio_knee.*normative_mom(:,2) ...
norm_imp_ratio_hip.*normative_mom(:,3)];

% Calculate residual
% (50 x 3) (50 x 3) (50 x 3)
res = normative_mom - (impaired_mom + exotendon_mom);

% Return the (currently unweighted) objective function results

% Squared so all values are positive
J = sum(sum(res.^2));