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Copyright © IFAC Mechatronic Systems, ELSEVIER

Sydney, Australia, 2004



D A Bradley', M Hawley!, P Enderby\ S J Brownsell!, S MawsolI t
and C Acosta-Marquez'

• Unil'ersity o/Aberray Dundee. Bell Street. Dundee DD I I HG. Uf:
: Barnsley District General Hospital. Gall'ber Road. Barnsley .)'75 ]£P. U /\
* University a/Sheffield. Northern General Ho.lpital. Sheflield S5 7A U. U/\
t Sheffield Hallam University.

Abstract: Increasing pressures on physiotherapy services, the need to increase the
involvement of patients in their treatment and the development of telecare technologies
all mean it is necessary to consider new ways of providing the levels of support and
treatment required. The concept of an integrated and intelligent system based around the
use of an exoskeleton to support patients and physiotherapists during rehabilitation is at
the heart of the NeXOS project. The paper discusses the development of the NeXOS
concept. and of the interdisciplinary nature of the programme, aimed at providing a
prototype system capable of being integrated with patient support services using web-
based strategies. Copyright K;l 200.; IFAC

Keywords: Mechatronics, Engineering Design, Automation, Rehabilitation

I. INTRODUCTION Where mechanical systems are used, as for instance
in the case of a Continuous Passive Movement
Physiotherapy is an important component in the (CPM) machine that might be used following knee
rehabilitation process for individuals with a wide surgery, these are currently relatively limited in their
range of lower limb disabilities . In order to maintain operation and capability. are difficult to set up and
soft tissue tlexibility and promote the relearning of need frequent monitoring and adjustment, as for
Illotor patterns, repetition of the movement, over an instance when a patient moves position slightly. This
extended period of time, of the lower limbs through a is not however to say that there have not been a
series of controlled motions is essential. number of attempts to produce automated and semi-
automated systems to support the rehabilitation of the
Typically, this is achieved by the physiotherapist upper and lower limbs . These include systems such
directly moving the lower limb, requiring a as the Lokomat produced by Hokoma [Hokoma,
significant degree of physical effort on behalf of the 2003], the TEM system developed by Sakaki et 01
physiotherapist and meaning that they can only deal [Sakaki et aI, 1999], the REHAROB project [T6th et
with a single individual at a time. Further, the aI, 200 I] and the Leg Extension system produced by
requirement that the manipulation is carried out Monitored Rehab Systems [CMDSport, 2003], all of
manually means that it is not possible to provide which aim to provide a range of motion types for
additional specialist treatment at other times, for different purposes. In addition. use is being made of
instance in an individuals home environment as part Functional Electric Stimulation (FES) based on
of an extended telecare package. external electrodes to provide for and enhance lower


which had the controls for the walking function team that was assembled to take the programme embedded in th eir handgrips. This exoskeleton system uses a operation for both walking and rehabilitation resulted I inear actuator to activate the knee and to provide in the decision to proceed in the tirst instance with support for the walking function as suggested by the implementation of the rehabilitation function as Figure I . and of the exoskeleton concept around which it is based.. consideration was programme to develop an intelligent exoskeleton given to the possibility of using the exoskeleton as capable of providing ass isted walking to individuals the basis of a rehabilitation system for use with the with a range of lower limb disabilities [A costa- lower limbs . is supported by the UK Department of Health through its New and Emerging Applications Fig. 3. Using this strategy. control enabled the user to adjust th e height of the lift and. as shown in Figure wider range of prospective user groups. The paper discusses the initial stage of the design and development of a nove l form of rehabilitation system for the lower limbs which makes use of an exoskeleton to provide the required motion and which is capable of being used either locally or remotely. as for instance the cycling and standing systems developed at Glasgow University in the UK [Hunt. 2. the performance of which was compared with the predicted performance . 2001). where appropriate. known as Ne' XOS. The project 2. Additional skills are set out in Table I . Evaluation of the required modes of l\·1arquez. these to select the appropriate one as required . The paper therefore concentrates on the design processes necessary to meeting that need rather than the technologies to be used. Consideration is given to the solving of problems such as the communication between individuals with different domain expertise and ensuring that there is a common understanding of the requirements and of the means of so lution required.Fig. The project. Simulated stride pattern limb activities for purpose of therapy. the mathematical modelling of a range of so lution options for the kinematic structure.. Balance was facilitated by the crutches and created problems of communication that had to be 484 . 2003][Jaime et 01. The exoskeleton was devel oped into a quarter-scale laboratory model (Figure 3). Fig. Additional support during walking was this seemed to offer more immediate benefits to a provided by the use of crutches. senso rs in the crutches and shoes ensured a 4-point and the information ga ined has been used to support stance before a step could be initiated. I. Quarter-scale laborato ry model Tools such as viewpoint anal ysis and focu s groups have been used to assist in identifying requirements. BACKGROUND using video capture and analysis to contrast the theoretical and achieved moti ons. the length and speed of the While thi s grouping provided the necessary skills. it step. the forward provided a balance of technical and clinical user would be able to pre-define up to three gaits and sk ill s typical of many mechat ronic projects. is that of meetin g patient needs in relati on to the rehabilitation process. Computer generated mannequin with of Technology programmes and brings together crutches engineering design and mechatroni cs with clinical and operational requirements in meeting patient need . The key aspect of the development of the NeXOS project. Once the quarter- The Ne' XOS proj ect was developed out of a research scale model was function ing. 2002]. usin g the World Wide Web as a communication and control medium to link the patient with their support team during the rehabilitation process.

I Palienl Croups illustrated by Figure 4 where a physiotherapist is working with a member of the project team. there was a need to identity: 2 Active assisted' A group whose requirement was for passive 3 and 4 Resisted Functionally active muscle movements only. Table I: Project team structure provide a balance of operation in which motion Illay range frolll the purely passive in which the Team Member Role exoskeleton is entirely responsible for the movement University of System design and programme of the leg to active where the patient would be Abertay Dundee management working against the exoskeleton. University Sheffield Hallam Physiotherapy and user needs University This meant that for the purposes of the initial evaluation it was necessary to specify prospective Table 2: Oxford scale user groups whose needs would retlect these requirements in terms of the ability of the Grade Definition exoskeleton to both provide and resist motion.4. to help Systems such as the CPM machine and the TEM to maintain a basic conditioning of the lower limbs. currently achievable would be beneficial. each of the team members viewed the system from a A group whose requirement was for a range of di fferent perspective and required a different form of active-assisted movements involving the interaction. expressed in relation to their own specific requirement to adjust the response of the system skills. A specific problem that is not the user to exert no forces during the Illotion. but where a Illuch greater 5 degree of control over those movements than solved if a viable system was to result. Table 2. system referred to earlier are essentially passive in This requires that the physiotherapist move the limb their operations in that they act only to move the leg through a sequence of motions while providing through a defined series of movements and require support for the limb. to various General Hospital management combinations of active-assisted and resistive motions Sheffield Remedial systems and user needs within a cycle of operation. Typical exercise performed in the sagittal plane for SCI subjects showing tracks for ankle and knee. It is the use of these tools and the integration during the therapy or be required to leave the of the information that they provide that will be machine for any purpose and.The rehabilitation of patients mechatronic projects. o or 1 No activity Specifically. they do not allow for the exercising of the muscles.Spinal Cord Injury (SCI) patients undergo passive motion therapy. and relationships and others with the defining the supported by a literature and patent review. SYSTEM REQUIREMENTS Spinal Cord InjlllY . considered in the following sections. while others were concerned with establishing patient Based on meetings with physiotherapists. being purely passive. Thus. which would then Barnsley District Clinical expertise and patient be providing a resistance to motion. Fig. 3. The reasons for and ability to ensure a robust communication this decision were: between team members is a characteristic of most Knee Arthroplastv . it was interaction with the physiotherapists who would decided to establish the initial investigation around deploy the system. As already indicated. Specifically. patients undergoing Knee Arthroplasty (KA) and This difference of perspectives and the requirement Spinal Cord Injury (SCI) patients. these establish a basis frolll which development can take need to be reconfigured should the patient move place. and is thus an area to which following Knee Arthroplasty is often based on the particular attention has to be given. one set of team members were in relation to the movements achieved. A key addressed by this forlll of therapy is the observed loss feature of the Ne XOS exoskeleton is the ability to of Bone Mineral Density (BMD) leading to an 485 . as 3. this has meant using a variety of to provide purely passive articulation of the knee tools ranging from observation to analysis to joint following surgery. These concerned with an ability to express the operation of movements would be based around the Oxford the exoskeleton in terms of its motions and forces in scale used by physiotherapists and set out in order to define and implement control strategies. In the case of the use of a Continuous Passive Motion (CPM) machine Nl' XOS project.

System Task Plan L(MIlevel Mounting & Kinematics Controller Fixing I . Provide motivation to patients through feedback it should: on their performance against agreed norms and by allowing them to assume some degree of Enable a variety of motions and motion types as control over the rehabilitation process. then played back the actions of the physiotherapist.. 7..J 1 '1 PO'Ner Actualor5 Sensors Valve5 System Track Se. It to any change of patient position during the was also considered that.habllltation System (NEXOS) I' 1 . autonomously adjust these to maintain parameters such as force. Fig. 5.. Services Plltient ~ Extemal Patient Interlace Intermc. System IfoJorld Interlace Control Sf!tup Points Interface Software Softvr(ar. lower leg in order to try to alleviate the loss of BMD. accordingly. within definable limits. . some requirements for the exoskeletal system in that 7. Plan Fig. 2000][Dauty.. the initial focus of that patient's physical dimensions. 3. 3. p~ti. Supply Jomts Calibration Fig. Hierarchy of non-functional viewpoints increased risk of fracture [Kiratli ill (fl. a therapy process. J:. Monitor the forces exel1ed by the machine and 2000] and addressing this problem is something to the patient throughout a cycle and which consideration is being given. 1 Environment Extemal Supplieri Reliability Social Family Patient Physio Clinician EPR Safety Patents Stand3l'cH. for instance. with the different forms of motion based around a basic work programme then being adjusted defined motion. Identification of viewpoints using brainstorming lm<ll!lIioent R. machine to establish a baseline of relevant Enable the rapid reconfiguration to encompass activity prior to using the machine. and safety issues were identified 486 . system such as was being proposed would not be used remotely. include a dialogue with the conjunction with the user.. velocity and power Based on the above it becomes possible to establish within agreed and defined limits. . in the first instance. repeat' procedure in which the system recorded and 5. This determined by the physiotherapist in could.nt Physical Commumcations Intelligt'lnce Installation Structure . This could perhaps take the form of a 'teach and enabling its use in the home environment. Provide for 'jerk free' transitions and operation applied along the axis of the major bones in the throughout the cycle. Hierarchy of functional viewpoints Sy5tem Design Cost IPR . 6.. AutonomoLlsly adjust.2 Physiotherapists 4. Enable the monitoring and control of the forces 8. This groups identified the requirement for an interactive would enable patients to set the machine up procedure for setting up and configuring the system. Support a rapid and automatic set-up procedure for any individual patient based on knowledge In the case of the physiotherapists.. 1 Reference I. I. themselves rather than requiring assistance.J . 6.

. ··1··I .. + d. .: . .:-. interface By introducing virtual markers into the video images which will enable the user to have a degree of direct of a physiotherapist performing a series of control over the operation of the machine... Velocity vectors for path generation and research moved to consider both the development of representati on the physical structure of the exoskeleton and its control in parallel with the development of user which would become the subject of detailed study views through a combination of analysis and focus and evaluation as the kinematic geometry of the group studies. . Srrok~ PlIICt'flN'11t with Pol/nomilllll"d [xpont'nlhtllltthl~ analysis in order to be able to define the key objectives in relation to meeting the performance H.· d!'Cos-&. For instance.3 Functional Analysis tracks generated by the physiotherapist during manipulation as in Figure 9. which should then respond Having established a mathematical model of the track accordingly .ck +Flnal Error • P"" = Achie". Figure 5 shows the results of the brainstorming session using a whiteboard while Figures 6 and 7 show the resulting hierarchies. -.-···-·--·f.:-----'. it was necessary to perform a functional proposed for the control of the exoskeleton in which 487 . Achl ... Bt "'" W. This representation then Having established the basic requirements for the forms the basis of the control strateb'Y that is system. These can then be arranged to form Fig. _.. . for manipulative exercises (Figure 4) it is possible to instance in respect of their ability to terminate the extract information as to the range and types of operation of the machine in case of discomfort.J ..--.. 8...... ed Tr. X. x. .-.---·-- (a) MatLAIJ model (b) Generated tracks Fig. requirements for the exoskeleton .-.. which are then clustered to create the groups of functional and non-functional viewpoints. of the ankle..--.90 . The method chosen for carrying out this analysis was viewpoint analysis as this enabled the division of the identified Po~lUoo 1\·1 f'1I. .~ .. = X. .. ~... This information can then be performance. 1999].. . _.. Results of curve fitting routines for path hierarchy trees representing the interrelationships generation between the individual viewpoints. the Fig. there is the possibility that used to construct a mathematical model of the motion passive motion therapy may induce spasticity in of the ankle which can then be used to represent some patients [Skold.-... Using this . the onset of which must patients of different leg lengths as shown in Figure 8.'Sin-6j .--. and easily reconfigurable. 2000]. 4. 10 .· II x.. curve-fitting routines can then be used to establish a mathematical representation of the 3. including information about is also the need to establish mechanisms by which the the velocity profile established over a complete system can respond to direct measures of patient manipulative cycle.+ Bj . p ~ ... = .'.1 Analysis They also identified the need to establish an appropriate. 9..4 identifY the viewpoints.'lnd viewpoints into those directly concerned with the I physical operation of the exoskeleton (the functional ...-. There movements involved. .. )\:.. be detected by the system.d Position 4.. a brainstorming session is first used to U 1. . exoskeleton became established.-.. = dtSin -e: . Leg motion during rehabilitation using a track representation derived from video analysis I'IHilloll Mnsnu·cJ ·H. . i . viewpoints) and those concerned with its integration into clinical and other systems (the non)ill1ctional viewpoints) [Bradley et al. .. I +. T~'l =Tafgtlt PMitkln ~ Target Tr....~ = Y. approach..~ ~ d J'Co s ~ x.. SYSTEM DEFINITION Using the information obtained from the patient p " = Current Position groups and physiotherapists and combining this with the structure provided by the viewpoint analysis.

hokoma. The Jaime R-P.I . Smith. viewpoint health in spinal cord II1JUry.. Trans. c. extensive use has been made of system severity and location. B.. A. Spinal Cord Injured Patients. Y.. pp 239 . In for hip and knee joints of spastic patients. 37. 27. Thomes team on factors such as the structure of the interface CMDSport. 10C Use will be made of web-based strategies as the basis Press.248 databases and references. Mecharronics and the Design of' feedback from these groups has to date advised the Intelligent Machines and . (2003) and the information it should contain and the target www. Vol. Dawsan.. Conl on Rehabilitation systems analysis methods are being combined with Rohotics. pp 55 -62 Work with focus groups has to date been with Bradley.. No 2. supported by reference to relevant clinical 5)ls. 1998]. Archives of' Physical modelling and visualisation taols to support the Medicine and Rehabilitation. Paper 6 exoskeleton and its related system components. doing so.F.A. No 12. Enabling exercise for fitness and On the basis of the requirements analysis. Bone.... Perrouin Verbe.. IEEE Neur. intelligent Exoskeletal Aid for Gait Assistance. This control provided for this project by the UK Department af strategy is a modification of that which was used for Health through its New and Emerging Applications the Lancaster University Controlled Intelligent ofTechnolagy (NEAT) programme. Conl on -1.. (2000). Seward. Mokhtari. Density and Geometric Changes through the Femur with Immobilisation due to Spinal 6. 21.. A..1.4 other forms of analysis to enable the system concepts Skold. D. Control and Operation of an identified as a key clinical groups and has Autonomous Robotic Excavator. develops. Okajima Y. different control and aperatianal strategies as well as Integration qf'lnf'ormatiol1 Technology in the to finalise the kinematic geometry of the exoskeleton.F. Nauenberg. pp relevant target groups of users and of the 73 -97 requirements for the introduction of a system such as Bradley. Rehah. (1999). & Tanaka N. Pmc.. & Burge. . Vol. (2003). Arz G. Kallfeltz.actuators are controlled to move the ankle along a 7.309 Hokoma. SYSTEM DEVELOPMENT www. J.~vstel11s. D. T. (i" 1nl. Ne XOS within a rehabilitation environment. Loughborough.I 16 of both local and remote communications with the exoskeleton and with stakeholders. process. T6th A. D. Vol. Levi.. Information Age. Okda S. specialists caming together to develap and (1999).. system is thus based around establishing appropriate Paraplegic standing supparted by FES- communication between the physiotherapist and the controlled ankle stiffness. evaluate the physiotherapy system with industrial robots. Journal of' concentrated on establishing their views on the Il1Ielligenl and Robotic Systems. conventional engineering design and Pmc. B. each of which represents the desired The authors would like to acknowledge the support movement in a specified time interval. (2001). Varga Z.E. pp 109 .1 Focus Groups Climbing and Walking Robots CLAIVAR '(il. The orthopaedic physiotherapists as these have been Development. (2002). An structure [Brad ley..cmdsport.. Spasticity to be integrated with stakeholder need. (2000). S. (200 I). pp The NeXOS project is an integrated and cross. TEM: Therapeutic Exercise Machine implement a new form of rehabilitation system. & Matghe. l!vlechE analysis. additional focus groups involving users Dubois. pp I . CONCLUSIONS Cord Injury. & Bradley D.Applications incorporating the principal features of the & Sollltions. Eng. patient identification and to store previously defined C.1557 and to stakeholders through facus groups.. pp 305 . D. As the project Dauty. No 2. 225 . R. Following on from the analysis and modelling stages. 5. The (2000). D. & Seiger. & Hunt K. for instance to establish Kiratli. Vol. ACKNOWLEDGEMENTS track defined as a series of linked velocity vectors as in Figure 10.A.. Vol. Conceptual design of an upper limb the development rig will be used to. patient. As part afthis after traumatic spinal cord injury: Nature. Of' the -/''' 1nl. Supralesional will be established to obtain their input into the and Sublesional Bane Mineral Density in design process.htm I environments for system introduction. & Seward. Excavator (LUCIE) which demonstrated that the velocity error and the rate of change of that error in a REFERENCES track following situation could be used as the inputs to an expert controller based around a production rule Acosta-Marquez C. Maugars. 488 . 10. Journal qf Rehabilitation Research and Development. ICORR '99.. M (ed).html Hunt KJ . (2003).com/monitor/mr_leg. I.. system analysis and focLls groups it Workshop on Mechalronics in Medicine. Matjacic Z.. M. (1998). becomes possible to create a system schematic Healthcare & Rehahilitation . & Varga P. Bone Mineral motion profiles. 80. communication of ideas between the project team pp 1548 disciplinary project which invalves a range af subject Sakaki T. & Perkash..