Technology foresight study on assistive technology for locomotor disability

Abstract

Physical disabilities minimize the participation of a person in desired activities and in the worst situation, fully prevent participation. The persons with disabilities (PwDs) have all along been forced to rely on various devices, gadgets, tools etc. to get themselves mainstreamed through such supports, collectively termed as Assistive Technologies (ATs). This research examines the current status of various ATs for PwDs in India and looks back to trace their evolution, to foresee the ATs likely to evolve by 2035 and offer a hope, to possibly reduce the gap between disabled persons and the normal to a maximum extent. Examination of the available literature, Horizon Scanning and Patent Databases (WIPO, USPTO, and IPINDIA) has been used for secondary data and an opinion survey for primary data. Two round Delphi study has been conducted on selected 29 ATs with the help of a panel of experts (hailing from industry, R&D institutions, academia, NGO, government etc.). The experts were asked to speculate the likely time-frame of adoption/commercialization of these ATs and were provided with broad trend of evolution of technology in past decades to help them in responding. The findings of Delphi exercise, bringing out potential assistive technologies with their time-frames, have been reported in this study.

Keywords

Disability horizon scanning Delphi patent PwD assistive technology impairment foresight locomotor

1. Introduction

Disability is the aftereffect of an impairment that may be physical, cognitive, mental, sensory, emotional, developmental, or some combination of these, that imposes restrictions on a person’s ability to participate or being part of something which is considered “normal" in his/her way of life. Impairment may be present from birth or strike during a person’s lifetime. According to the United Nations Organizations (UNO), disability is the interaction between persons with impairments, impediment, attitudinal, and environmental barriers that restrict their complete and effective involvement in society on an equal basis with others. A physical or mental impairment is one that prevents a person from fully utilizing their senses and/or coordinating those senses with motor skills. For example, a person suffering from paralysis, blindness or person who is not able to walk or eat on their own can be considered as a person with disability (PwD).

According to the World Health Organization [1], it is estimated that more than a billion people in the world today experience some kind of disability. In developing country like India, disability is one of the most important issues to deal with because 80 to 90 percent of PwDs of working age are unemployed, compared to 50–70 percent in developed countries. India with 17.5% of the world’s population is the second most populous country in the world with a population over 1.21 billion people and more than 25 million of them are having some form of disability [2]. Figure 1 gives a snapshot of the population of disabled in select countries, reflecting the magnitude of the problem barring aging population.

Figure 1.

Population of the disabled in select developed and developing countries.

Figure 2.

Relative proportion of PwDs as per Census India 2011.

India has come across tremendous development in last 10 years which has attracted a lot of international gaze and envy but unfortunately, about 22% of our population still remains below the poverty line. According to Census of India (2011), 75% of PwDs live in rural areas and cannot afford the luxury of using advance technology-based assistive technology (AT) to move on with an independent life. As per as Census of India [2], this population is grouped into eight different types, depending on the disabilities that limit them from being a normal compatriot, and they are visual impairment, hearing impairment, locomotor disability, mental illness, mental retardation and multiple disabilities. Figure 2 gives the relative proportion of different categories of disability as per Census 2011. It is quite evident from the figure that motor disability counts the highest percentage of disability, and perhaps the most neglected as it is often felt that this group does not need any special care or attention like the other categories (viz. visual, mental, hearing impaired) and thus characterized as an underrepresented group in the disability movement.

1.1 Locomotor disabilities

Locomotor impairments lead to disabilities that affect a person while performing motor tasks such as walking, running, grasping, manipulating objects, handwriting and other fine motor skills. In general terms, a person is considered as locomotor impaired if he or she exhibits a motor coordination significantly below what is expected for his or her age. In that sense, cerebral palsy, spinal cord injury, muscular dystrophy, cerebrovascular accidents, dystonia, accidents and others, are considered as locomotor disabilities [3]. In order to make these people socially and economically involved, there is a persistent need of special tools or technology, i.e. Assistive Technology so as to enhance their participation in desired activities and thus make them independent to the maximum extent. With this need to empower the people with disability, governments and organizations all over the world have framed various norms and policies. US, Europe, Canada, WHO, etc. have been pioneering the enabling policies and have influenced the shaping of policies in other countries. Table 1 gives an overview of such interventions in India, evolved to improve the status of persons with disability [4].

Table 1
Key points from prominent initiatives of the government for PwDs in India

Government of India Initiatives	Highlights
Assistance to Disabled Persons for Purchase/Fitting of Aids and Appliances (ADIP)	Aims at helping the disabled persons by bringing suitable, durable, scientifically manufactured, modern, standard aids and appliances within their reach
National Trust for Welfare of Person with Autism, Cerebral palsy, Mental retardation and multiple Disability Act, 1999	Has a provision for legal guardianship of the four categories of the persons with disabilities and for creating an environment to enhance their independency as much as possible.
National Policy for Person with Disabilities, 2006	Development of assistive technology, promotion of research etc.
National Knowledge Commission, 2009	All schools must be designed and geared for inclusive education, which means that all systems must be oriented to enable the greatest possible access to children with different needs and abilities. This needs major changes in both infrastructure and pedagogical methods.

1.2 Assistive Technology (AT)

AT is the field of engineering that addresses the development of methods, systems, and devices to assist people with disability, so that they can carry out activities of daily living. In that sense, an AT device is one that can be used to increase or improve functional capabilities of any individual who may suffer from disabilities [2]. ATs range from simple devices such as crutches and tri-cycles for mobility impairments, special spectacles for a person with visual impairments, and hearing aids for dealing with hearing impairment, to complex ones, such as software for screen magnification, talking books, cochlear implants etc.

Over the years, it has been shown that ATs can be powerful tools to increase independence, to improve learning and cognition, and for rehabilitation and recovery of many kinds of injuries. In general, these technologies can help in reducing or completely eliminating disabilities [2] and thus ensure dignified and independent lives for PwDs [1].

As mentioned earlier, India has the highest population of a person having locomotor disabilities (approx. 20%) and perhaps the most ignored section of people in term of research and technology. The main reason for this is lack of research on assistive technology for locomotor disability, especially in Indian context. There is significantly less study on assistive technology for locomotor disability. Moreover, there is no foresight study on future assistive technology for locomotor disability to the best of our knowledge. This study focuses on people with locomotor disability. We have also assessed the different ATs available in the past and the present and tries to make an extrapolation and being mindful of the non-linearity of the future by using the wisdom of experts.

2. Literature review

Much work has been conducted in developing and evaluating ATs for patients who suffer from a locomotor disability [6]. But literature has put less emphasis on PwDs. They have rather focused on the elderly population. We have come across few studies relevant to our scope work that emphasize on AT for locomotor disability. Glover [7] developed a robotically augmented walker. It was designed to park itself and to return to the user when signaled. The main purpose of this walker was to reduce the risk of falls, for a person with motor disabilities. AT for people who cannot stand up by themselves, who cannot perform coordinated movements, or who have impairments due to blindness have also been developed. Tsukahara et al. [8] proposed a support system for paraplegic patients who cannot stand up by themselves, using a robot suit called Hybrid Assistive Limb (HAL). Bae and Moon [9] presented an electric lifting chair designed to aid in standing up and sitting down. Basteris et al. [10] developed a robot designed to treat cerebellar symptoms (for instance, tremors and inability to perform coordinated movements) and locomotor symptoms (such as muscle weakness). Hasegawa and Oura [11] introduced an exoskeletal meal assistance system for progressive locomotor disability patients.

AT systems and devices rely on different kinds of signals or feature coming from the environment or from the human operators of the device. In this regard, temperature, velocity, orientation, force, torque and many other quantities can be detected and used. There are few studies centered on electromyographic (EMG) signal such as those generated by muscle activity, as they can be used for controlling AT devices. EMG have been used in many application for people with locomotor disabilities, including prosthesis, computer interface, wheelchair control, exoskeleton robots and other AT devices [12, 13, 14, 15, 16]. These signals are specifically useful to interface the users with AT devices connected to limbs and face because they are generated when there is muscle activity [17].

Many researchers have focused on gesture-based approaches to control AT devices rely on specific motions of the hand, face or other parts of the body to send a command or instruction to the AT devices. Rivera and DeSouza [12] developed a power wheelchair controlled by different hand gestures. For instance, closing the hand was translated into a command to stop the wheelchair or tapping the fingers made the wheelchair turn left and so on. People with locomotor disabilities may not be able to execute the same gestures that other people can. However, their limited movement can activate other muscles [17]. For example, a person in a power wheelchair with no dextral impediment may be able to move wheelchair using a joystick.

An examination of different studies carried out on ATs brings out the fact that most of the research has focused only on developing ATs for a person with locomotor disabilities rather than identifying its value in the society. The value can be determined by the amount of population who can afford these technologies. These ATs use advanced technology like sensors, artificial intelligence (AI), EMG etc. that makes it very costly. In developing country like India, 75% of PwDs live in rural areas; facing poverty cannot afford these devices. Therefore, it is high time to come up with such technologies which can reach to every single person having any kind of disabilities. This study is an attempt to fill the above-mentioned gap and focuses on the systematic foresight of Assistive Technology for locomotor disability that has the possibility of reaching Indian market in next 15–20 years.

3. Methodology

It is very well known and accepted that a foresight cannot be based on extrapolation of the present. As future evolves in a non-linear fashion, any objective foresight approach or methodology should typically involve a combination of foresight methods, as no foresight method by itself can give credible foresight. Depending on whether the intended objective is a scenario or a vision or a forecast, the approach and hence the methods or their combinations can be selected.

In this foresight study, a projection has been attempted with a belief that the future is an extrapolation of past and present into the future. The study looks at the past and the present and tries to make an extrapolation and being mindful of the non-linearity of the future also banks on the wisdom of experts. The inputs to a foresight study are in the form of data and insights; at times data is used to generate insight and vice versa. Data collection and information derived from it plays a very crucial role in foresight work to get a credible result.

Figure 3.

Source of data or information on technologies.

Figure 4.

Output from methods used.

Figure 3 reflects the sources of data (information on technologies) in the present study. Available literature on the topic, horizon scanning, and patent database have been used for secondary information while opinion survey and Delphi study were resorted to, for generating primary data. The study has been conducted to gather relevant technology information that formed data, obtained from following sources:

•

Past technologies (Literature Search);

•

Present Technologies (Literature Search, Survey and Horizon Scanning);

•

Future Technologies (Horizon Scanning, patent and Delphi).

Information on the past and present technologies were used in the questionnaire for a Delphi study to seek expert’s opinion on the time – frame of futuristic ATs for locomotor disability. It is tendentious to make forecasts and expect them to be close to the extrapolated present; therefore, the involvement of experts was important to effect non-linearity in the study. Figure 4 gives the output of each method and its contribution to the study.

3.1 Methods

A literature search is the backbone of any research work. This is important for the assessment of state-of-the-art of a topic, identification of the experts, and identification of key questions about the topic and determination of methodologies used in similar studies. Every study has a finite time frame for completion and keeping this constraint in mind, a literature search is the best suited and tested way to gather information quickly and credibly from an academic text, journal, dissertation, research project, article etc.

In this study, a literature search has resorted to data collection – basically information on (the past as well as present) technologies. It was done by some background reading of books (like Assistive Technology for Visually Impaired and Blind People, by Hersh and Johnson; Assistive technology: Shaping the Future, Craddock), articles (on the topic of assistive technology, disability, healthy ageing, foresight etc.) and encyclopedias to get a grasp of the research topic and build a context for the study.

Literature survey helped in examining the evolution of ATs for locomotor disability. This, when plotted on a timeline and looked at with the most recent developments, gave an idea of possible ATs of the future. It delineates the evolution of different assistive devices and their impact on disabled people.

Table 2
Keywords used for searching patents

Technology	Keywords
Prosthesis	Prosthesis, Prosthetic, Artificial Limb, Prosthetic Leg, Prosthetic Arm or Hand
Wheelchair	Wheelchair, Chair car
Exoskeleton	Exoskeleton, Exoskeleton Walker, Exosuit, Exoframe, Artificial Body Covering
Bionics	Bionic, Bionic Prosthetic, Bionic Limb, Bionic Arm, Bionic Leg
Crutches	Crutches, Forearm, Underarm, Platform, Leg Support)
Orthotics	Orthoses, Orthotics, Braces, Splint, Wrist Support, Ankle Brace
Brain Implant	Brain Implant, Neural Implant

Some of the major keywords used, during literature search are as follows:

•

‘Assistive Technology’ or ‘assistive aid’ or ‘assistive devices’ or ‘rehabilitative device’ or ‘adaptive device’

•

Locomotor (or ‘locomotion’ or ‘mobility’ or ‘motor’ or ‘ambulation’ or ‘movement’)

•

Disability (or ‘impairment’ or ‘disorder’ or ‘problem’)

Horizon scanning is done routinely in TIFAC, on technologies, showing up on the global technology landscape and scan-hits shared on TIFAC’s Facebook page. Database of scan-hits of the year 2014 and 2015 was used to pick promising technologies. A list of websites has been used for which relevant scan-hits were sourced. In all, 146 assistive technologies were identified and categorized on the basis of following attributes:

•

Sector (artificial intelligence, biomedical, nanotechnology, information and communication technology and mechanical)

•

Functionality (medical aid, mobility aid, visioning aid, navigation aid, intellectual aid, hearing aid, daily living aid, multiple aids, communication aid, holding aid, reading aids, entertainment aid, writing aids, traveling aid and leisure aid)

•

Disability (locomotor disability, visual impairment, hearing impairment, mental illness, mental retardation, multiple disabilities, speech impairment, and any other).

As the focus of this study was on locomotor disability, 50 technologies out of 146 were found to be relevant as ATs for locomotor disability. A thorough study of all 50 technologies suggested that they could be placed on seven distinct technology tracks, viz. Prosthesis, Wheelchair, Exoskeleton, and Bionics, Crutches, Orthotics and Brain implant. Several technologies out of 50 had similarities in terms of their working principle, but were of different manufacturers and were taken as one for this study. Further, the technologies that were basically pharmaceuticals, clinical treatments, diagnosis or technology for regenerating organs were filtered out, as they were not ATs. Twenty-one technologies for locomotor disability remained after the scrutiny.

Patent Search was another quicker way to gather information on futuristic technology, given the time constraint for the present study. In this study, international patent databases like WIPO, USPTO and Indian patent database, i.e. IPINDIA were searched to gather some futuristic ATs. Table 2 gives the keywords used for searching the patent databases.

Databases for the years 2014 and 2015 were looked into for ATs which are not yet commercialized in India but show promise for the disability sector. In all, 4 technologies were identified from this method.

A survey was conducted to get insights on future Assistive Technology by 2025. The idea behind the survey was to get an expert’s take on futuristic ATs that may have been missed during scanning and a literature search. One hundred and fifty experts from academia, R&D, industry, government officials, etc. were asked to speculate future ATs for locomotor disability; presented in the questionnaire. For better understanding and clarity to the respondents, technology tracks- prosthetic, exoskeleton, wheelchair, wheelchair, bionics, crutches, and braces were spelled out in the questionnaire. The survey did not add any new technology, suggesting that scanning and patent search gave reasonably rich information.

A total of 29 technologies were identified (collected from horizon scanning, patent search and four speculated by the interns at TIFAC). We then, conducted a Delphi exercise on these 29 technologies to get the convergent opinion of the panelists on likely time-frame of adoption/commercialization of the 29 technologies in India.

3.2 Delphi study

Popular qualitative foresight method, Delphi was used in this study. It is a consensus building tool and requires formation of an interactive panel of experts. These participants must be willing to share their expertise and work toward a consensus on matters of opinion. For this study, experts from all over the country, with experience and knowledge in assistive technology and disability sector, were approached through email to constitute the panel.

Beginning in January 2016 and ending in May 2016, the Delphi panel participated in two rounds, responding to questions which called for thoughtful and detailed responses. As discussed earlier, this foresight study is on assistive devices for locomotor disabilities, placed on seven tracks viz. Prosthesis, wheelchair, exoskeleton, crutches, bionic, braces and brain implant. The questionnaire for Round 1 was sent out to 200+ individuals from academia, industry, government, NGOs, and R&D, two questions were asked of the panelists on 29 futuristic technologies identified under these tracks. The panelists were provided with timelines for each track, delineating the evolution to help them make a projection into the future and respond to the questions. The predominant respondents who turned out to be young experts from academia, industry and R&D organization were asked:

(a)
The time-frame in which you (they) expect technology to be adopted (commercially available) in India along with reasoned opinions.
(b)
The technologies (in the timeline) that will get replaced by new one.

In all, 48 responses were received in Round 1 within the stipulated time; the responses were examined for consensus. At least 75% respondents agreeing over two or three adjoining time-frames were adopted as criteria for consensus [18, 19, 20], applying this criterion; consensus was obtained for 15 technologies out of 29. The technologies on which no consensus was there were considered for the Round 2 of Delphi. All the 48 panelists of Round 1 were informed about the technologies on which consensus had emerged; this was through the questionnaire for Round 2 that included all the 14 technologies on which consensus eluded. The new questionnaire carried with it- the group statistical response, comments, objections and arguments (obtained in Round 1) for each technology, offered by the panelists as feedback; while maintaining the anonymity of respondents as warranted by Delphi. In a few cases, recent developments were provided as additional information, to help the panelists decide on their response in Round 1 to maintain it or alter it; thus ensuring a dialogue among participants, another feature of Delphi. In all, there were 38 participants in the panel (or respondents in the final round of Delphi). After the final round of the Delphi survey (Round 2), it was observed that 25 technologies out 29 had consensus on their time-frames while 4 did not viz. Prosthesis powered from body heat, Mind control exoskeleton, Exoskeleton cum wheelchair and Compressible assistive products.
4. Results

The experts in the Delphi study comprised of having 50% from academics, 20% from healthcare organization, 15% from R & D (lab) and remaining 15% from industry, a non-government organization (NGO) etc. Based on the data collected and analyzed in this study, there were a variety of opinions and suggestions among experts. After analyzing all the 38 responses from Delphi study (final round), we found that 25 ATs out of 29 had consensus over their arrival in the Indian market in next 20 years. Table 3 provides the time-frame of 29 selected futuristic assistive technologies based on the expert’s opinion.

Table 3
The time-frame of futuristic assistive technologies based on the expert’s opinion

Assistive technology	Time frame
	0–10 Years	0–15 Years	5–10 Years	5–15 Years	5–20 Years	No consensus
Robotic Arm Controlled By Muscles Activities		$\surd$
Fully Integrated Prosthetic Limbs and Bionic Implants		$\surd$
3D-printed Iron Man prosthetic		$\surd$
Adjustable Length Prosthetic Foot		$\surd$
Brain-Controlled Robotic Arm				$\surd$
Modular Prosthetic Limb		$\surd$
A Brain-Computer Interface That Lasts for Weeks				$\surd$
Prosthesis Powered From Body Heat or Energy						$\surd$
3D Printed Wheelchair		$\surd$
Shock Absorbing Wheel for Wheelchair	$\surd$
Hi-tech Wheelchair for Rough Terrain			$\surd$
Hands-Free Wheelchair	$\surd$
Smart Controlled Bionic		$\surd$
Bionic Prosthetic That Can Feel Grip Strength					$\surd$
Cyberlegs				$\surd$
Bionic Leg Prosthesis Controlled by Subconscious Thought or Brain				$\surd$
Free Hand System – To Revive Paralyzed Hand					$\surd$
NeuroBridge – For Limb Movement					$\surd$
Underarm Crutch With Power Generation Function		$\surd$
Folding Crutch Chair	$\surd$
Crutches Having Joint		$\surd$
Robo-Ankle Flexes Artificial Muscles		$\surd$
3D Printed Exoskeleton		$\surd$
Bionic Exoskeleton					$\surd$
Motorized Pants for Stroke Victims		$\surd$
Mind Control Exoskeleton						$\surd$
Exoskeleton Cum Wheelchair						$\surd$
Household Robots		$\surd$
Compressible Assistive Product						$\surd$

In the time-frame of 0–10 years, three technologies- shock absorbing wheelchair, hand free wheelchair and folding crutch-chair are likely to commercialize or adopted. The technology, as per experts is known but is not getting adopted because of the fear of the new. Though it is likely to have these ATs in the market soon, some experts do feel that artificial intelligence takes time to develop a system that will be highly accurate in its learning and exhibiting abilities.

A lot more changes can be expected if we further our time-frame by another 5 years. Development of technologies like prosthetic controlled by muscle activities, 3D printed prosthetic, modular prosthetic limb, 3D printed wheelchair, and smartphone-controlled bionic prosthetic, 3D printed exoskeleton, crutches having joints – will allow disable people to work more effectively in a competitive environment. It suggests that technology based on 3D will get adopted in India between 10–15 years, offering the benefits of customization to PwDs. According to experts, these technologies have already been deployed in a few developed countries and this augurs well for its adoption in the Indian market soon.

In the time-frame of 5–15 years, new technologies such as 4D technology and brain-computer interface (BCI) will emerge and potentially be a game-changer for the PwDs in India. Brain-controlled prosthetic, mind control exoskeleton and brain control bionic, could become commonly available.

Brain implant is one of the most critical milestones achieved in term of technology and is likely to impact disability sector in India between 5–20 years. It is expected that it can help people with disability to regain the movement of their paralyzed limbs. This technology is in a nascent stage, even in countries like USA, UK etc., so it’s highly unlikely for technologies based on brain implants like NeuroBridge and free-hand system to get adopted/ commercialized in India in next 10 years.

As discussed earlier, BCI is used to operate prosthetic or bionic limbs, but as per as experts’ opinion, it is very complex to implement the same for exoskeleton even though it is successful in the laboratory; the reason for this might be the size of exoskeleton that makes it difficult to operate with the help of brain or thought.

With the advancement of the technology, it is also expected that few technologies will get replaced with other technology. One Delphi panelist has opined that there is a possibility of wheelchair getting replaced completely by the exoskeleton. Also, as both bionic and prosthetic are almost same in working, bionic will replace prosthetic in coming years because 3D technology will make it easy and economical manufacturing.

Experts from R&D organizations and academician have emphasized on one specific issue, which is the acceptance of these ATs among PwDs. They feel that only a few technologies have potential to reach among PwDs (low-cost technology). According to them, it is unexpected that rural population of India can afford technologies such as Brain-controlled prosthetic, mind control exoskeleton and brain control bionic even in next 20 years. They also feel that all the technologies identified in this study have a potential that can irreversibly change the status of PwDs in India. However, the challenge would lie in taking these technologies to the needy, which might be geographically or financially challenged. Necessary interventions may have to be devised by the government to facilitate and make affordable these technologies to help PwDs living in either rural or urban area and give them independence and dignity.

5. Discussion

It is difficult to compare our results with other existing studies because there is no such study has been done earlier particularly in the Indian context. However, this study can provide a solid foundation for the future researcher to continue working in this area.

The study was conducted with certain limitations and upon completion; it is felt that there is a scope for further work. The technologies studied on the timeline can be investigated further to identify the causes of the change and base them for better foresight.

Insight from defense scientists working in this area could be integrated.

SWOT analysis for each technology in Indian perspective for prioritization of ATs for funding by government and also adoption and usage by PwDs in India.

Extension of a foresight study to another type of disability like visual, hearing, speech, etc., by incorporating the points given above.

The probability of Assistive Technologies getting commercialized or adopted in India could be given.

Footnotes

Acknowledgments

The authors would like to sincerely thank the two anonymous reviewers for their pertinent comments and suggestions for this paper, which not only improved the quality, but also the presentation of this paper. The authors want to thank Technology Information Forecasting and Assessment Council (TIFAC) for providing all the resources to carry out this research, and special thanks to Mr. Yashawant Dev Pawar, Scientist E (Patent Facilitating Centre).

Conflict of interest

None to report.

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