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      The Cybathlon: Where Paraplegics Walk Again The Cybathlon: Where Paraplegics Walk Again
      ETH Zürich/Alessandro Della Bella
      October 19, 2016

      The Cybathlon: Where Paraplegics Walk Again

      In a staging area in the Swiss Arena, home of the Kolton Fliers, a professional hockey team on the outskirts of Zurich, Switzerland, Tyson Cobb crouches at the feet of his friend and teammate, Mark Daniel, and fiddles with the footstraps of their exoskeleton. Peter Neuhaus, a senior research scientist at the Institute for Human and Machine Cognition in Pensacola, Florida, and the exo's lead engineer, stands nearby. The three are trying to remain calm, but it's not easy. In about ten minutes, Daniel, a 27-year-old paraplegic with no sensation below his bellybutton, will pilot his exo—their exo—in the first heat of the Cybathlon, billed as "the first international competition for people with disabilities supported by modern assistive technology." It wasn't long ago that Daniel thought he'd never walk again. Now, he's about to be in a foot race.

      Outside the staging area, the sellout crowd of about 4,600 roars. There are paper noisemakers, cow bells, whistles. A Swiss television channel broadcasts live from a temporary studio erected in a corner of the stands. Billy Howell, IHMC's media specialist, likens the atmosphere to a football game. "We were hoping it would be engaging," he says. Nobody thought it would be like this.

      Throughout the morning, Neuhaus has shown his nerves more than the others. The atmosphere is one factor. He worries Daniel might lose focus and, worst case, fall. Like a true engineer, it's something he tried to anticipate and plan for. When practicing back in Pensacola, the team did their best to simulate the noise and distractions of a sports arena. They invited local journalists to pepper Daniel with questions before and after he walked. They played a song called "Hips Don't Meow," a close relative to the Meow Mix jingle, repeatedly. They deployed a smoke machine.

      Still, Neuhaus has reminded Daniel to concentrate so many times over the past few days that it's become something of an inside joke. "Focus," he told Daniel during yesterday's final practice. "Block everything out."

      "Yeah," another IHMC engineer cracked. "Especially Peter."

      Neuhaus smiled. "I'm nervous," he said.

      During a practice session prior to Cybathlon, Tyson Cobb straps Mark Daniel into the exo. Credit: Brian Blickenstaff

      Perhaps more than anyone else on the team Neuhaus has the right to be nervous. He has spent the bulk of his life's work in the field of robotics, and the Cybathlon, with its crowd and its live TV broadcast, is probably the most public exhibition a project of his has ever received.

      "This is his last ten years of research culminating," Cobb says.

      In the sitting position, the exoskeleton resembles a chair with a backpack, which contains a computer, attached to the seatback. Daniel loops his arms through the backpack's straps. Cobb harnesses him to the exo's carbon-fiber legs, which are custom-fitted to Daniel's body, with joints mirroring those of Daniel's knees, ankles, and hips. After the footstraps, Cobb moves to the calves, the quads, the belt. The process takes nearly five minutes. Finally, Daniel grabs two forearm crutches.

      The right crutch has a joystick on the end of the handle, which Daniel can manipulate with his thumb, and a button beneath that, to click with his index finger. A small tablet is mounted to the crutch as well, off to the side of his arm. He uses the tablet and controls to select for various options, like the length of the exo's gait, or, in this case, having the exo go from a seated to a standing position.

      Click.

      The movement seems effortless and smooth. Aside from a few beeps from the computer—an indicator of high torque on the joints—Daniel stands in near silence. The crutches are just for balance. The exo does all the lifting.

      Click.

      He takes a step.

      Click.

      Another.


      When the Swiss Federal Institute of Technology in Zurich, known simply as ETH, first announced the Cybathlon, engineering groups around the world jumped at chance to showcase their cutting edge technology designed to enhance the lives of disabled people. In total, 66 teams from 25 countries would take part. Organizers hope to make it a quadrennial competition, and smaller, more frequent regional competitions are already in the works.

      There are events for people missing arms who have prosthetics so sensitive and versatile they can screw in a light bulb and hang laundry on a clothesline, tests of dexterity for people with prosthetic legs so advanced that participants not only walk without a limp but can hopscotch through an obstacle course. There's a bike race where participants, paraplegics, have implants in their legs or external stimulators that flex their muscles in the pattern necessary to pedal a bike. They control the speed with a hand throttle.

      A competitor on a Functional Electrical Stimulation Bike. Credit: Brian Blickenstaff

      The competition's stated aims are to "facilitate conversation between academia and industry [...] technology developers and people with disabilities and to promote the use of robotic assistive aids to the general public."

      But beyond those lies a less obvious goal: Cybathlon is an attempt to answer an age-old question, one that all researchers, whether in academia or the private sector, have encountered, usually far more frequently than they would like: How the hell are we going to pay for this?

      The intersection of robotics and prosthetics has led to some amazing breakthroughs, but research is expensive. Typically, researchers find money through venture capital or government grants, sometimes both. Neither source of income is especially secure, however, and projects are often funded only in the short term. The date at which the money dries up is a familiar source of dread for every project leader in the field.

      The hope among Cybathlon participants is that by turning "modern assistive technology" into a sport, they'll attract the attention of the brands that spend big—an estimated $45 billion per year, globally—on sports sponsorship.

      It's a big gamble: in addition to the $2,000 entry fee and travel for IHMC's ten-member team, it cost Neuhaus about $1,000 to just to ship the exo from Florida. All that, and the first Cybathlon doesn't offer any prize money. For Neuhaus, though, the potential to attract sponsors alone is worth the cost of participating. Current funding for IHMC's exo comes largely through grants and local philanthropists. At one point, Neuhaus also received money from NASA. The project's annual budget is around $250,000, but Neuhaus says they "could really use $500,000 to a million a year, to really do it right."

      The sponsorship income, if it materializes, will be especially important to the world of robotic prosthetics. The short-term market for exoskeleton technology isn't paraplegics striving to regain their independence but rather therapists helping people with less severe injuries relearn motor skills. Some exos already have limited FDA approval, but before exos become a widely recognized therapeutic tool—and before insurance companies begin covering them in large numbers—companies will need scientific evidence showing their value. All that testing will be expensive and time-consuming, and it's a big part of why Neuhaus designed an exo for paralyzed people rather than for rehab.

      "We felt like [an exo for paralyzed people] was a pretty realizable goal, and it had very measurable success criteria, versus something for rehab, which has this whole extended process of efficacy and results of studies," Neuhaus says. "Here, [Daniel] started on one side of the room and he walked to the other side of the room, and he couldn't do that without this device, so therefore it works."

      Increased mobility isn't the only benefit an exo provides. Paraplegics spend their lifetimes seated, which can lead to circulatory and digestive problems. Muscles atrophy, bones lose density. Standing and walking, even if a person's legs aren't doing the heavy lifting, can help all of the above.

      There's also a psychological payoff. "And it goes beyond just, you know, reaching into the cabinet to get the cookies that my wife might hide up there or the good booze," Gary Linfoot, a paralyzed Army veteran, recently explained to NPR. "You know, when you go out to a social setting, back up at six-foot, talking to somebody eye to eye, you get the sense of dignity, and the disability just kind of fades away into the background."

      Daniel during a practice walk. Credit: Brian Blickenstaff

      Daniel describes standing in much the same terms. During his first training session in Zurich, he had a particularly powerful experience. He walked to the hotel elevator, took it down to the bar, and ordered a drink—a glass of water. To not only stand and look people in the eye but order a drink from the bar? Put it on the list of experiences Daniel, who was injured at 18, never expected to have. He's not the type to get emotional about this sort of thing, but the team knows what it means to him, and they tell everyone who will listen about his glass of water. Howell has a hard time recounting the episode without looking like he might burst into tears.

      Despite the benefits the technology could bring to the disabled, Neuhaus suggests that a future in which it's commonplace to see paraplegics walking the streets is at least ten years away. It's not just a waiting game on the science. As with rehab exos, the potential for devices built for mobility are muddled by insurance questions.

      The problem is the wheelchair. The current generation of exoskeletons, while impressive, are not yet real competitors for the wheelchair. Exos are difficult for a paralyzed person to get into without assistance, they're far slower than a wheelchair, and they don't yet possess the dexterity needed to maintain balance without crutches. (Exos piloted by people with less severe injuries, like stroke victims or paraplegics with limited leg function, are far more maneuverable and don't all require crutches.) For Neuhaus, the really exciting science going on now centers on "having the hardware make decisions about what it should do—whether it's maintaining balance, or where to step, or if they're falling how to step to keep in balance—versus the operator making those decisions, and how the two work together."

      Comparisons with wheelchairs will become less compelling as exo engineers begin to solve this human-machine interaction, but over the next ten years or so, the question remains: If an exo doesn't dramatically increase a patient's quality of life relative to a wheelchair, why would an insurance company pay for it? And might they resist covering injuries that occur while using this new technology?

      The exo-versus-wheelchair calculus is likely to pass the critical threshold in Europe before it does the United States. There is some irony here. The passage of the Americans with Disabilities Act of 1990, and the wave of curb cuts and access ramps and elevator installations that followed, turned the U.S. into what is probably the world's most wheelchair-friendly country. This infrastructure takes away many of the mobility advantages early exos might have over a wheelchair—you don't need to walk up the stairs when the adjacent ramp gets you to the same place.

      European countries, on the other hand, have made no comparable commitment to disabled mobility, which Daniel realized when he first explored Zurich in his wheelchair. Many of the city's bars, restaurants, and shops have skinny walk-up entryways that make them downright inaccessible to Daniel. The cobblestones make for a rough ride, which leads to leg convulsions. The convulsions come from something called spasticity, a condition that results when nerve signals—as innocent as a muscle tick or as worrisome as the touch of a hot stove—don't reach a person's brain, where they would normally be shut off. Without that signal from the brain, the nerves don't so much stop as shake themselves out.

      The life-changing potential for an exo in Europe was made most apparent while touring the ETH research center a few days before the Cybathlon. Mid-tour, Daniel found himself in need of a toilet. He was directed to the men's room and then left in privacy. But the bathroom was tight. He couldn't even get his wheelchair in. It wasn't the first time Daniel had found himself in this position, but it may have been the first time he had to slide out of his chair and drag himself across the cold tile at a laboratory dedicated to bettering the lives of the disabled.


      Daniel grew up outside Pensacola. He spent his childhood largely seated on a dirt bike. "I started on a dirt bike when I was four, five years old," he says, "and by the time I was seven, I blew that dirt bike up."

      He loved the power, the acceleration, the rush he got from the bikes, and admits to being the family daredevil. Dirt bikes taught him to weigh risk and reward and to fall gracefully.

      "I didn't know Mark before he was in a wheelchair," Cobb says to me at one point, "but I bet he was fucking wild."

      Here in Zurich, Daniel constantly looks for hills to ride down. His chair does not have breaks, and he stops by touching his fingers to the wheels. The tires have treads like a dirt bike's. He does his best to avoid elevators, and holds a special affinity for escalators. He rides them with his feet facing up, his arms spread wide to grip the handrails. Neuhaus stands directly behind him, a step or two below, just in case. Daniel likes to wait until they're about halfway up or down, when Neuhaus has begun to relax, before pretending to lose his balance.

      The two make something of an odd couple. Neuhaus, who is in his 40s, is married with two daughters. He earned his PhD in mechanical engineering from Berkeley and did his undergrad at MIT. He has a runner's build, short brown hair, and a casual West Coast demeanor. He speaks with a faint lisp but no placeable accent. Daniel is an outdoorsman, born and raised on the Redneck Riviera. When he doesn't hear someone properly, he responds with "Sir?" or "Ma'am?" He has a background in welding, a trade he learned at Job Corps, a Department of Education program that is as much halfway house as it is vocational training center. Students at Job Corps are not allowed to leave. They sleep and study on the same campus. Daniel likens it to a prison, but credits it with saving his life. When he went to Job Corps, in Greenville, Kentucky, he was 17 years old and addicted to cocaine.

      IHMC pilot Mark Daniel and team leader Peter Neuhaus. Credit: ETH Zürich/Alessandro Della Bella

      Following his stay in Greenville, Daniel returned to Pensacola and immediately found a job welding. The gig payed well and came with as much overtime as he could take. Although he was no longer using, Daniel remembered a thing or two about how to function on little sleep. He began working long hours, sometimes more than 80 a week. But he was happy, even with the punishing schedule.

      "I was on top of the world at 18, man," he says. "I was doing what I wanted to do."

      On the day he broke his back, in 2010, he had been home for three months. He finished a 14-hour shift at the Mobile shipyard before getting in his truck for the 45-minute drive back to Pensacola. "I remember, wow, kinda falling asleep and catching myself," he says. "And then the next thing, I woke up three days later in the hospital." He had a breathing tube down his throat and his arms were tied to the bed so he couldn't pull it out. His T10 vertebrae was destroyed, and with it a section of his spinal cord.

      That same year, Neuhaus, who had started working with exos two years earlier, in 2008, after receiving some grant money, was in need of a test pilot. His search took him to West Florida Rehab, where he met Daniel.

      Neuhaus' first exo had been designed to help people swim, but while testing the model one freezing winter day in an above-ground pool in Pensacola, it occurred to him what a terrible idea a swimming exo was. There are better ways to propel people underwater, for one thing. More to the point, one should think twice before "you mix things that sink with things that shock you, and water." He was smarter than that.

      What followed were a series of different walking exos. The current model is Neuhaus' fourth. They had a few different test pilots before Daniel, but they were either too big or too risk averse. Daniel, Neuhaus quickly realized, was an ideal candidate. For one thing, he weighs about 160 pounds and has the physical strength to move himself around when not in his chair. More important, he's not worried about falling.

      "The dude will try anything," Robert Griffin, a visiting researcher at IHMC, says.


      As Daniel, Cobb, and Neuhaus prepare in the Cybathlon staging area, competitors in the exo category's first heat make their way to the starting line. The heat includes just three teams: Neuro Walk, from Russia; SG Mechatronics, from South Korea; and a Mexican team, Roki.

      The race consists of a six-part obstacle course. The competitors have ten minutes to complete the circuit. They and earn points for each obstacle they complete and can skip as many as they want. The obstacles are weighted for difficulty and competitors progress from easiest to hardest, as follows: They must sit down on and stand up from a low IKEA couch; walk a short slalom; walk up a ramp, open and shut a door, and descend another ramp; walk along a number of unevenly spaced stepping stones; walk across two angled platforms; and, finally, walk up and down a flight of stairs.

      Neuro Walk's sleek, white exo appears to malfunction before the race even begins. After huddling around the pilot, troubleshooting the problem, the Russian engineers pick him up and carry him to the starting line, exo and all. The others assemble without incident. Once set, a baritone, robotic voice counts down, and numbers flash on the Jumbotron screen. Three. Two. One....

      SG Mechatronics steps toward the couch, sitting quickly. The Roki is slower off its line. The Russian pilot doesn't move.

      As IHMC's engineers watch, their eyes aren't so much on the race progress as they are on the technology. They study how their competitors power the various joints, thinking about weight and structure, balance.

      The day before, while the IHMC team waited to turn their exo over to race officials at a nearby conference center, the Roki team made a grand entrance. The engineers wore sombreros and Mexican flags as capes. Two Roki team members had their exo's legs casually thrown over their shoulders. IHMC's engineers were briefly unsettled. The Mexicans were jovial and confident. Although nobody at IHMC said so, they seemed intimidated.

      Roki's exo is a commercial product, available for purchase in Mexico. The company advertises it as "the most accessible exo on the planet," with an after-tax price tag of $13,990. IHMC's model, on the other hand, is not for sale. IHMC is a research organization affiliated with Florida's university system, and the exo wasn't even produced with a commercial future in mind. What's more, Daniel began walking in their current version just 8 weeks ago.

      IHMC and Roki pose together the day before Cybathlon. Credit: Brian Blickenstaff

      The teams compared notes. IHMC's exo is more powerful, but at 75 pounds is almost twice as heavy. The Roki is operated with the help of a walker rather than crutches, something that never even occurred to the IHMC engineers.

      After expecting the Roki, Travis Craig, an IHMC research associate, took a step back, smiled. "It's always interesting, when you get a bunch of engineers together and ask them to solve a problem, how many different answers they'll come up with," he said.

      The IHMC team wasn't sure if the walker was an advantage until now, standing in the Arena, watching the Roki in action. Roki's pilot moves slowly. His exo seems underpowered, struggling with his weight. The pilot's face takes on a pained expression. His walker shifts from side to side, threatening to buckle under its heavy load.

      Using crutches, the SG Mechatronics pilot fares much better, although as he attempts to stand, his crutches slip and he nearly falls. He pauses, steadies himself, and rises from the couch. He then walks nimbly through the slalom and up the embankment to the door. He's already far ahead of the other two.

      He opens the door without issue. It's closing the door that is tricky. The exos don't balance well laterally, which makes it hard to do something like lean back and grab a door handle. Many of the pilots, Daniel included, will close it with a hook on the end of a crutch. The Korean pilot has a different tactic: he ties a piece of string to the handle. The door closes as he walks through.

      It's moments like these that seem to excite the engineers most. As impressive as the technology might be, the engineers regard simple, well-executed solutions with a kind of reverence, and a string around a door handle was downright genius.

      "This is about our pace," Jesper Smith, another IHMC engineer, says as SG Mechatronics reaches the stairs. As the pilot is descending, with just a couple stairs left, time expires. The Roki pilot doesn't even complete the slalom. Yury Sidorov, the Russian, fails to so much as stand up off the couch without assistance. He finishes with zero points.


      As Daniel approaches the starting line, some IHMC team members can't watch. Suddenly everyone is superstitious. Smith tells me his mere presence is "bad voodoo." He doesn't watch with the rest of the team. Other engineers admit to having a kind of cursed touch. They're only allowed to handle the unit once it's broken. If everything goes to plan, they won't touch it in Europe at all.

      Daniel puts on an impressive performance, acing the stepping stones—the event he feared most. His exo is the only exo in the competition with actuators on his ankles, which generate power like a human calf muscle. The feature allows Daniel to generate forward momentum even after a particularly large step, when his legs are spread wide. But while the ability to "toe off" is an advantage on the stepping stones' large steps, the plates under his feet make lateral balance tricky, and the team decided to skip the slanted path. The risk of him falling wasn't worth it.

      Daniel finishes the heat seconds behind a 44-year-old German named Andre Van Rueschen, whose exoskeleton, made by a company called ReWalk, is probably the world's leading commercial model.

      IHMC pilot Mark Daniel preparing to stand from the couch. Credit: ETH Zürich/Alessandro Della Bella

      Van Reuschen stands about six-foot-two, and has a build that suggests a retired athlete. His ReWalk moves him with ease. But it does not have a powered ankle. Van Reuschen skips the stepping stones, citing that as the reason. He did, however, complete the tilted path, which is worth more points than the stones. Although their total times were close, Van Rueschen goes into the final with a seven-point lead over Daniel.

      The final will put Daniel against the other overall top finishers: Van Rueschen, SG Mechatronics, and a Swiss team, PolyWalk EPFL, piloted by Silke Pan, a former trapeze artist and the only female exo pilot.

      The IHMC team immediately begins dissecting the performance. Daniel, believing his exo to be superior, is convinced he can catch Van Rueschen. He twice selected an incorrect walk mode during the first race.

      "I fix those, that's 30 seconds right there," he says.

      The discussion continues in the locker room, which is shared with two other teams. Exos lie flat on tables like bodies in a morgue. "Should we add more toe-off?" Cobb asks. It wouldn't take much work with the computer to instruct the ankle actuator to operate with more power.

      Neuhaus says no.

      "We ain't changing shit," Daniel says.

      Then Neuhaus reminds the team of the rules. The winner is decided by points. Time is only a tiebreaker. Assuming ReWalk and IHMC skip the same obstacles they skipped in the first run, ReWalk wins.


      Standing on the starting line ahead of the final, a television camera closes in on Daniel, and he smiles broadly, his image filling the Jumbotron.

      "Look at Mark, cheesing for the camera," Craig says.

      The crowd roars in anticipation. A huge drone made to look like a human eye hovers overhead. The event's two horrifying mascots, which look like large, post-apocalyptic troll dolls, wrestle in the area behind the starting line. The robotic voice counts down. Daniel heads for the couch.

      He sits first and begins to stand, but his crutches slip twice. Still, he gets to his feet before the others. He walks the slalom in first place, but ReWalk catches him on the ramp and beats him to the door. It's close. They're within seconds of each other. They make it through the doorway at the same time, closing the doors almost simultaneously. But at the bottom of the ramp, Daniel loses his balance and begins to teeter.

      "He's got it," Craig yells at the three spotters around Daniel, who are raising their hands and preparing to grab him. Craig doesn't want them to touch Daniel unless he's really falling—if they help him, he'll be disqualified from that obstacle. "He's got it!"

      After a wobbly second or two, Daniel recovers without assistance. Deep breath. He proceeds across the stepping stones. The Korean pilot isn't far behind. Daniel clears them without trouble. The Korean pilot does not. After a couple steps, his exo's legs visibly bend out at the knees. They appear to be buckling, but sideways. As fans around the arena brace themselves for a sickening fall, the spotters step in and grab him. His race is over.

      Korean pilot Byeongwook Kim on the stepping stones. Credit: ETH Zürich/Alessandro Della Bella

      The Swiss team also fails to complete the course when their system has a processing failure in the first few minutes.

      Daniel and Van Rueschen march on, unaware of the drama behind them. They get to the stairs, the final obstacle, at the same time, and begin to climb together. Daniel pulls ahead briefly. His ankle actuators give him the power to climb one foot to a stair. Van Rueschen, meanwhile, stands on each step.

      Van Rueschen, however, has the advantage on the descent. People with spinal cord injuries often suffer from decreased joint flexibility as a result of disuse, and Daniel's ankles no longer have the requisite range of motion for him to step down stairs while facing forward. Van Rueschen's do. And while Daniel turns around, Van Rueschen catches him and beats him across the finish by a matter of seconds.


      In the locker room after the race, the team talks about celebration. Is the concession stand still open? How much is a beer? Nobody knows.

      What they do know is that second place is a hell of a finish. Before the Cybathlon, they thought they would be competitive, but nobody expected a medal. Furthermore, they'd beaten several production exos and lost by the faintest of margins to a man who has owned his exo for more than two years. Van Rueschen uses it at home all the time. Daniel had practiced in the IHMC unit for exactly two months.

      "It keeps us relevant," Neuhaus says later. "We survive on our reputation."

      IHMC Pilot Mark Daniel and Cybathlon champion Van Reuschen. Tyson Cobb looks on. Credit: ETH Zürich/Alessandro Della Bella

      What's next? It's a question the team hasn't thought much about, but once the thrill of competition subsides, real life looms. Neuhaus will go back to Pensacola and continue working on some other projects. He'll search for funding and write grants. Daniel is planning a five-day road trip to London with a few other team members, but after that his future is a bit fuzzy. He's currently employed as an IHMC intern, but when his internship ends, he will be jobless, which is how things have been, for the most part, since his injury. He has plans to become the first person to ride the length of the American Discovery Trail, from Delaware to California, in a wheelchair, and has some sponsors lined up, but won't set out until the weather warms.

      Before the team packs up for the night, a film crew visits the locker room. A correspondent tries on the exo, commenting on its power. For the disabled, the device is empowering and exhilarating. To ride it as an abled body person is an exercise in giving up physical control to a machine. It is not something that comes naturally. Wearing the exo, it is difficult to shake the notion that, if it somehow went haywire, it could tear you to pieces.

      While still strapped in, the correspondent interviews Neuhaus. They talk about the technology a bit. After a moment, Billy Howell, IHMC's media specialist, jumps in. He makes a point about how Daniel, who is no longer part of the interview and is seated by himself off to the side, will still be in his wheelchair after all of this.

      The correspondent seems briefly unsure what to say. He puts another question to Neuhaus, who doesn't answer right away. He looks down, brings a hand to his face. Through choked back tears, he says he wishes Daniel could take the exo home.

      Daniel wheels over. He's fighting tears now, too. He puts an arm around Neuhaus.

      "Someday, I'll get one," he says.

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