2019 IEEE 16th International Conference on Rehabilitation Robotics (ICORR)
Toronto, Canada, June 24-28, 2019
Bio-inspired tendon driven mechanism for simultaneous finger
joints flexion using a soft hand exoskeleton
Mohammed H. Abdelhafiz1, Erika G. Spaich1 , Strahinja Dosen1, and Lotte N.S. Andreasen Struijk1

Abstract— A new tendon driven mechanism, embedded into a
soft hand exoskeleton for rehabilitation and assistance, was
proposed in this study. The proposed solution was a pulley
flexion mechanism inspired by the human musculoskeletal
system to enable a natural and comfortable finger flexion. A
biomechanical constraint for the finger flexion motion states that
the relation between the proximal interphalangeal joint angle of
the finger should always be flexed around 1.5 times the distal
interphalangeal joint angle. The study aimed to comply with this
constraint, by simultaneously distributing the forces over the
distal and middle finger phalanges. For evaluation, the
voluntary and exoskeleton flexions were compared based on the
relation between the proximal and distal interphalangeal joint
angles. The results showed that during the exoskeleton flexion
the relation between the interphalangeal joints complied with
the biomechanical constraint, where the proximal
interphalangeal joint angle was 1.5 times larger than the distal
interphalangeal joint. This ensures that the mechanism flexes the
finger comfortably. The proposed solution is therefore a
promising design for a novel soft exoskeleton that will be used
for training and assistance of patients with hand paralysis.
I. INTRODUCTION
According to the world health organization, an estimated
500,000 spinal cord injuries (SCI) occur every day [1]. Upper
limbs are impaired in more than 50% of the cases [2] and this
consequently, affects the quality of life. The upper limb is
essential for interacting with the external environment, by
grasping objects using its distal joints (fingers) and
manipulating them using its proximal joints (shoulder and
elbow). Physical Rehabilitation of the upper limb in the early
period (up to 6 months) after stroke can result in faster and
better motor recovery [3].
Recent studies show that training distal and proximal joints
together is more effective than training them separately [4].
However, due to muscle weakness and difficulty to instruct
and support both joints (Proximal and distal), the therapists
focus on the proximal joints then the distal [5]. This
rehabilitation strategy consumes more time; therefore,
Rehabilitation robots have been introduced since they can
assist therapists to train both joints together. Several
rehabilitation devices have been developed for the
rehabilitation of the upper limb and especially for hand
(fingers) function [6-12]. Exoskeleton devices that use rigid
links, [6-7] for hand rehabilitation can provide accurate and
complex hand movements, but they usually rely on
complicated mechanisms for applying force and encoders for
posture measurements. This often results in bulky and heavy
devices. The range of motion of the fingers and their mobility,
Mohammed H. Abdelhafiz, Erika G. Spaich, Strahinja Dosen, and Lotte
N.S. Andreasen Struijk are with SMI®, Department of Health Science and
978-1-7281-2755-2/19/$31.00 ©2019 European Union 1073
which are important for rehabilitation exercises such as
picking up small objects, may be restricted due to the bulky
design of the rigid exoskeletons, and in addition, their weight
might make them uncomfortable for long rehabilitation
sessions. To obtain compact and lightweight design, joint-less
tendon driven hand systems have been developed [8-12].
BiomHED [9] is a glove that assists the affected hand in
performing dexterous movements by using three tendons
mimicking the human finger tendons. However, this requires
more than one actuator for each finger to be able to perform
the movements. To reduce the number of actuators, several
devices have been developed focusing only on performing
flexion and extension movements simultaneously with several
fingers as they are the most used to perform activities of daily
living [10], [12-14]. The SEM glove [12] is a tendon driven
device that flexes the thumb, middle and ring finger using
tendons providing assistive forces during grasping. The Exo-
glove [14] assists the hand, not only during flexion, as the SEM
glove, but also during extension. Several other gloves that
provide flexion and extension movements have been
developed, e.g., Popov et al [11], In et al [14] and others [10],
[13].
The musculoskeletal structure of the human finger creates
constraints on the flexion motion; one of these constraints is
the interdependence between the Distal (DIP) and Proximal
(PIP) interphalangeal joints, where the PIP joint angle should
be around 1.5 times the DIP joint angle [15-16]. The constraint
should be respected in order to have a comfortable finger
flexion. Otherwise, the extensor tendon that runs on the dorsal
side of the finger and inserts on the middle and distal
phalanges, will be stretched more than it should, generating an
uncomfortable and painful feeling [16]. The traditional tendon
mechanisms mainly use one tendon fixed at the distal part of
the distal phalange mimicking the function of the Flexor
digitorum profundus tendon. However, it has been shown that
one tendon is not enough to perform a natural movement as it
will violate the biomechanical constraints [17].
The present study describes the development of a new
mechanism for a joint-less tendon driven exoskeleton (glove),
which can assist performing flexion finger movements
respecting the biomechanics of the human hand. The design
also considers the portability demands. The mechanism was
evaluated experimentally, by comparing the voluntary flexion
of the hand with the flexion obtained when the proposed
mechanism was used.
Technology, Aalborg University, Denmark. (Corresponding author: E-mail
naja@hst.aau.dk).
 II. DESIGN CONCEPT AND PROTOTYPE
There is a strong correlation between the DIP and PIP
joints of the human finger during flexion [18]. This is due to
biomechanical constraints that pertain to the structure of the
finger musculoskeletal system [16]. Designing a soft hand
exoskeleton that takes into consideration the correlation
between the DIP-PIP joints and does not exceed the
biomechanical constraints of the normally moving fingers, is
essential to prevent harmful movements of the fingers during Figure 1. Anatomic Structure of the finger with the flexor
hand flexion. (green and yellow lines) and extensor tendons (red line).
Analysis of the anatomy of finger flexion provides middle phalange but, by the aid of the pulley system, it also
information about how to perform a flexion that respect the contributes to the flexion of the MCP joint flexion. The FDP,
finger constraints. Therefore, the proposed flexion mechanism also by the aid of the pulley system, contributes to the PIP and
of the soft hand exoskeleton is inspired by this anatomical MCP even though its end is inserted on the distal phalanx.
system.
Overall, both of the MTUs (FDP and FDS) are critical for
A. Finger flexion anatomy finger flexion. Research investigating the ratio of contribution
The human finger consists of three phalanges: proximal, of FDP versus FDS, concluded that FDP is contributing 1.15
medial and distal, in addition to the metacarpal bone that is times more than the FDS to the finger flexion motion [22].
considered as the root of the finger and it is located in the palm Such force ratio allows the finger to respect the DIP constraint
of the hand [19]. The phalanges and the metacarpal bone are (i.e. the opposing extension force of the extensor digitorum
connected together by means of ligaments, which are an elastic tendon on the DIP joint) and does not exceed it. Therefore, in
tissue [20], to create three joints: the metacarpophalangeal this study, we mimicked the structure of the human flexor
joint (MCP), the proximal interphalangeal joint (PIP), and the system considering also the biomechanical constraints of the
distal interphalangeal joint (DIP) [19]. finger.
The tendon of the extensor digitorum communis (EDC) B. The proposed flexion mechanism
runs along the dorsal side of the finger. It has a long tendon To achieve a compact mechanical structure, the proposed
that is inserted on the dorsal side of the middle phalanx and design is implemented as a tendon driven soft hand
then gives two lateral slips that run on both sides of the middle exoskeleton. Supra wires (Fladen fishing, Sweden), with a 0.4
phalanx to reunite again when inserting on the dorsal surface mm diameter and maximum load of 100 N, were used as
of the distal phalanx [19], as shown in Fig. 1. Due to this tendon for the exoskeleton. For guiding the tendons, rounded
structure of insertion of the EDC tendon, The DIP joint angle shape, wooden pearls, with 3mm outer diameter and 1.5mm
depends on the PIP joint angle during flexion. When the PIP diameter hole, were employed.
joint flexes the lateral slip widens and becomes loose giving
some space for the DIP joint to flex, while it narrows and Passing the flexion tendons along the mid-line of the finger
becomes tight when the PIP joint extends, which reduces the phalanges on the palmar side will deprive the user from having
range of flexion of the DIP joint [16]. This generates a a direct contact with the grasping object (i.e., the tightened
constraint on the movement of the finger while flexing, where tendons will insert between fingers and the object). Therefore,
the maximum flexion angle of the DIP joint is functionally
depending on the PIP joint flexion angle.
The finger flexion muscles are structured in a way that
respects the interdependence between the DIP and PIP flexion
angles. The system consists of two extrinsic muscle tendon
units (MTUs), where the muscles are located outside the hand
on the volar side of the forearm. The flexor digitorum
superficialis (FDS) actuates the PIP and MCP joints, while the
flexor digitorum profundus (FDP) contributes to the PIP, DIP
and MCP joints. The FDS and FDP tendons generate from the
respective muscle and runs towards the fingers. At the
proximal phalanx, the FDS tendon bifurcates into two tendons
and re-attaches after that to be inserted in the middle of the
middle phalanx while the FDP tendon passes between the
bifurcated FDS tendon and inserts on the distal phalanx [21].
Such structure allows the flexor tendons to apply aligned Figure 2. Schematic of the proposed flexion mechanism
flexion forces on the middle and distal phalanges. These flexor (palmar side); Orange line: exo-tendons, Blue lines: wooden
tendons are surrounded by a sheath, which is a walled tube pearls fixed on the glove allows the exo-tendons to pass through
connected to the phalanges with a low friction inner surface them. Green line: exo-tendon used to pull the mechanism to flex
allowing the tendons to slide inside it. This structure creates a the finger. Red rectangle: wooden pearl that allows the exo-
system that looks like a pulley for finger flexion. The FDS tendon (orange line) to pass through it and be pulled by the other
tendon has the ability to flex the PIP joint as it is inserted at the exo-tendon (green line)

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six guidance wooden pearls were located on the radial sides of
the proximal, middle, and the distal phalanges allowing the
tendons to pass along the radial sides of the finger. Two more
guidance pearls were located on the tip of the distal phalanx
and on the dorsal side of the middle phalanx. One exo-tendon
was used to represent the function of both the FDS and FDP
tendons in the real human finger, Fig. 2. This exo-tendon will
have a starting point at the end of the first metacarpal bone
before reaching the MCP joint. The FDS tendon was
mimicked by passing one end of the exo-tendon from its
starting point through the guidance pearls on the left side of
the finger, ascending upwards until the middle phalanx, and
then descending it on the right side of the finger to be fixed
further down beyond the starting point. This balances the
forces on both sides of the finger. The FDP tendon was
mimicked by routing the other end of the same exo-tendon
from the same starting point (i.e. at the first MCP joint) then
passing through the pearls on the right side of the finger and
ascending until the distal part of the distal phalanx to descend
through the guidance pearls on the left side of the finger. On
the distal phalanx, the exo-tendon passes through a Bowden
cable to prevent it from being overtightened around the distal
phalanx when the exo-tendons are tightened.
In this study, the exo-tendon was pulled by a DC motor
using another exo-tendon (green line, Fig. 2) that connects the
actuator to the finger through a Bowden cable (SP352, Carl
Stahl). At the finger side, the two exo-tendons are connected
together with a wooden pearl (red square, Fig. 2), to create a
pulley system that divides the force equally between the two
sides of the exo-tendons generating a force ratio equal to one
between the side that represents the FDS tendon and the other
side that represents the FDP tendon.
The tendon mechanism was implemented using a leather
glove as a base, Fig. 3(a). The glove was strengthened in the
middle of the three phalanges by sewing a non-stretchable
fabric to it. On top of this fabric, the guidance pearls were
attached to the glove using a thread (liner Ø0.26mm, Fladen
Fishing, Sweden) that can hold forces up to 90 N. On the
actuator side, an EC Maxon motor (Ø22 mm, brushless, 25
(a)
(b)
Figure 3. Overview of the prototype (a) the glove side (palmar
side of the index finger) (b) the actuator side
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Watt) with a Planetary Gearhead (Ø22 mm, 0.5 - 2.0 Nm) was
coupled with a power screw (Ø 8 mm), Fig. 3(b). The power
screw mechanism was used to convert the rotational motion of
the DC motor to a translational motion to pull the exo-tendon
that is connected to the nut of the power screw.
III. EVALUATION OF THE MECHANISM
To evaluate if the proposed flexion mechanism can flex the
finger in a comfortable and natural way, the flexion motion of
the hand made by the implemented prototype was compared
with the voluntary finger flexion. A single male subject (32
years old), with hand size of nine, conducted the experimental
evaluation. The subject gave written consent to participate in
the experiment.
The flexor muscle activity of the subject was recorded
during the trials in which the hand was flexed using the
exoskeleton. This signal was compared with the muscle
activity while the subject relaxed his hand (baseline signal) to
ensure that the muscle was relaxed and did not contribute to
the hand flexion when the exoskelton is used. One pair of
surface electrodes (Ambu Neuroline, Inc.) was aligned with
the flexor digitorum muscle fibers on the forearm using a
bipolar configuration with an inter-electrode distance of 2 cm.
The reference electrode was placed on the elbow. Both of the
EMG signals which have been recorded during exoskeleton
flexion and the relaxed signals (baseline signal), were
segmented into 0.25 s windows to calculate the signal power.
The T-test has been applied to compare the signal power of
both EMG signals. The trials that showed statistically
significant difference (p < 0.05) with respect to the baseline
were discarded.
The flexion kinematics of the index finger was recorded by
using 8 Qualisys Oqus 300/310 cameras. The three
dimensional position of the reflective markers (spherical, 4mm
dia.) was recorded at a sampling rate of 100 Hz. Six reflective
markers were attached directly over the glove. They were
placed as following: front tip of the distal phalanx (FT), distal
side of the middle phalanx (DIP), distal side of the proximal
phalanx (PIP), distal side of the first metacarpal (MCP1), distal
Figure 4. The Position of the markers and joints angles
side of the second metacarpal (MCP2) and the proximal side
of the first metacarpal (CMC). This method of placing the
markers was chosen, as it does not impede the normal flexion
of the finger joints [23].
The trajectory of the finger joints angles (DIP, PIP, and
MCP joints) were computed. The three points MCP1, MCP2
and CMC represent the hand plan with an x-axis along the
̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
𝐶𝑀𝐶 𝑀𝐶𝑃1 vector, y-axis normal to the x-axis towards the
palm. The x and y axes of the hand plan creates a plane normal
to the hand plan called sagittal plane. The vectors that
represent the phalanges, ̅̅̅̅̅̅̅̅̅̅̅̅̅̅
𝑀𝐶𝑃1 𝑃𝐼𝑃 (Proximal phalanx), (a)
̅̅̅̅̅̅̅̅̅̅̅
𝑃𝐼𝑃 𝐷𝐼𝑃 (middle phalanx), ̅̅̅̅̅̅̅̅̅̅
𝐷𝐼𝑃 𝐹𝑇 (distal phalanx), were
projected on the sagittal plan to align the vectors [24]. From
the projected vectors the joints angles could be measured. The
angle of each joint is equal to the angle between the projected
vector of the phalanx after the joint and the projected vector of
the phalanx before the joint.
The DIP, PIP and MCP joints angles trajectories of the
index finger were measured in all the flexion trials. The
measured trajectories were filtered using a second order
Butterworth filter with a cut off frequency of 1 Hz. Each
flexion trial lasted 7 s. whatever the subject was prompted to (b)
flex the hand, the hand was flexed voluntarily, or the hand Figure 6. DIP and PIP joint angle trajectory during (a)
was flexed by the actuator pulling the exo-tendons during the voluntarily flexion, (b) exoskeleton flexion. The narrow line in
the middle of each trajectory show the average of the trials, and
use of the exoskeleton. These 7 s were considered as the
the standard deviation is represented by the shaded area. The
interval of interest where the motion capture system captured vertical lines shows the moments when the flexion speed
the finger motion. The EMG signals detected from the flexor exceeds the speed of 4 °/s for the first time (start of the motion)
digitorum muscle on the forearm were also recorded during and it also shows the moment when the flexion speed decreases
this 7 s interval. The signals were filtered by notch a filter at to be lower than 4 °/s (end of the motion).
50 Hz to remove power line noise and then filtered by a
second order Butterworth bandpass filter with the cut off the aid of the proposed flexion mechanism. These two
frequencies of 5 Hz and 500 Hz. The time was normalized experiments were repeated ten times for the same subject.
during the region of interest, and then the average and
standard deviation of the measured angles, at each step, for all IV. RESULTS
the trials that had the same task, were computed. The relation between the average DIP and average PIP
joint angle trajectories for voluntary finger flexion are shown
The subject was asked to extend the hand normally until the in Fig. 5. This relation is compared with the relation between
fingers were straight with respect to the hand palm without the trajectories of the same angles while performing finger
hyperextension. Then, from that position, the subject flexed flexion using the exoskeleton. The results show, that when the
the fingers voluntarily after the motion capture system started finger is flexed voluntary, there was a relation between the
recording. The same experiment was then conducted but with DIP joint angle and PIP joint angle, where the PIP joint angle
is 1.5 the DIP joint angle during flexion (average slope). The
PIP joint, during finger flexion using the exoskeleton was
slightly faster as compared to the voluntary finger flexion,
until the finger flexion got close to the end of the flexion
motion, where the DIP joint became faster than the PIP joint
(see the slopes of the DIP-PIP joint angles relation, fig. 5).
This created a curve that was always in the comfortable region
above the line showing the DIP-PIP angle relation during
voluntary flexion, Fig. 5. In this region the PIP joint angle is
always larger than 1.5 times the DIP joint angle.

The average of the DIP and PIP joint angles trajectories,

Figure 5. DIP-PIP joint angle relation during voluntary flexion
compared to exoskeleton flexion for one subject (average of 10
trials)
during voluntary flexion and during flexion using the
exoskeleton is shown in Fig. 6(a) and 6(b). The voluntary
flexion results show that both DIP and PIP joints starts to
move simultaneously and they also reach their final position

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*: fingertip - voluntary
*: DIP - voluntary
*: PIP - voluntary
o: fingertip – exoskeleton
o: DIP – exoskeleton
o: PIP – exoskeleton
Figure 7. The flexion of the finger at three different positions
(PIP joint, DIP joint and fingertip) for two conditions:
voluntary flexion and assisted by the exoskeleton.
Table 1 Range of motion of the finger joints
DIP PIP MCP
Voluntary 61.6° 92.5° 85°
Exoskeleton 55.6° 77.6° 86.7°
Difference 7.4° 12.2° -1.7°
at the same time. The DIP and PIP joints also flexed
simultaneously at 0.22 of normalized time when the finger
was flexed using the exoskeleton but the PIP joint reached its
final position at 0.78 while the DIP reached its final position
at 0.83. This shows that, in average, the exoskeleton flexion
of the PIP joint with respect to the DIP joint is faster 1.1 times
than the voluntary flexion of the PIP with respect to the DIP.
Even though the exoskeleton provided simultaneous flexion
for the finger joints, its range of motion was less than the
range of motion of the fingers during voluntary flexion.
The DIP and PIP joints range of motion reduced by 11.7%
and 13.5%, respectively, while the exoskeleton at the MCP
was flexed more than the voluntary flexion by 1.7° as shown
in Table 1. The flexion patterns of the finger joints (DIP, PIP
and MCP joints) for both voluntary and exoskeleton scenarios
are shown in Fig.7. As it is noticed, the flexion patterns for
both scenarios are close to each other but the range of motion
for the exoskeleton flexion was restricted at the end.
V. DISCUSSION & CONCLUSION
In this study a new joint-less tendon mechanism for a soft
hand exoskeleton was presented. The mechanism was
inspired by the human anatomical system. The mechanism
distributed the forces on the DIP and PIP phalanges so that
they flex simultaneously as in the natural human motions.
Further, the mechanism it did not violate the finger
biomechanical constraints, where the PIP joint angle should
be always 1.5 times the DIP joint or more to have a
comfortable flexion.
The new mechanism was evaluated in a pilot test
comparing the relation between the DIP and PIP joint angles
during voluntary flexion and flexion using the exoskeleton.
During voluntary flexion, there is a relation between the DIP
and PIP joints. This relation can be used to divide the DIP-
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PIP motion plane, shown in Fig. 5, into two regions. In the
lower region, the DIP joint would have a larger angle when
using the exoskeleton than during voluntary flexion, for the
same PIP angle. In other words, if the DIP-PIP profile would
be in that region, the biomechanical constraints would be
violated. Therefore, the finger should not be in that region
during the externally produced flexion motion using an
exoskeleton. And indeed, the results have demonstrated that
the DIP-PIP joint angle relation of the finger during flexion
using the novel exoskeleton was always on the comfortable
side of the motion plane. This was despite the fact that the
DIP-PIP joint angle relation when the exoskeleton was used
was not identical to this relation when the finger was flexed
voluntarily. The difference was generated because the ratio of
force contribution of the FDP muscle to FDS muscle during
finger flexion is around 1.15 for the normal human finger,
while it was always around 1 in the mechanism. This has
made the flexion of the PIP joint using the exoskeleton
slightly faster than the voluntary flexion. The force ratio could
be changed in the exoskeleton by relocating the guidance
pearls on the middle phalange to decrease the moment arm
and consequently decrease the torque applied on the middle
phalange. Nevertheless, it is still preferred to have a ratio of 1
in order to push the flexion motion in the comfortable region
and further away from the margin between the two regions.
The trajectory of the index finger’s joints angles during
voluntary flexion and during flexion, using the proposed
mechanism was also compared. By using the proposed
mechanism to flex the index finger, the DIP and the PIP joints
started moving simultaneously at the beginning of the motion
similarly to the trajectory of the joint angles during voluntary
flexion. However, they did not reach the end of motion at the
same time, because the flexion of the PIP joint, when the
proposed mechanism was used, was faster than the flexion of
the same joint when the finger was flexed voluntarily. The
range of motion of the PIP and the DIP joints angles using the
proposed device were lower for 11.7% and 13.5%,
respectively, compared to the range of motion of the same
joints during voluntary flexion. This was due to the leather
glove, used as base for the mechanism, which constrained the
fingers and prevented the full motion.
In this pilot study, the experiment has been conducted in a
single able-bodied subject. To generalize the results, the same
experiment should be conducted in a larger number of
subjects and in target patient population.
REFERENCES
[1] Bickenbach, J. , "International Perspectives on Spinal Cord Injury.,"
The international spinal cord society., 2013.
[2] Angel Gil-Agudo, Antonio del Ama-Espinosa, Ana de los Reyes-
Guzmán, Alberto Bernal-Sahún and Eduardo Rocón, "Applications of
Upper Limb Biomechanical Models in Spinal Cord Injury Patients,"
in Biomechanics in Applications, IntechOpen, 2011.
[3] Qiuyang Qian, Xiaoling Hu, Qian Lai, Stephanie C. Ng, Yongping [22] T.-H. Yang, S.-C. Lu, W.-J. Lin, K. Zhao, K.-N. An, P.-Y. Lee and
Zheng and Waisang Poon, "Early Stroke Rehabilitation of the Upper F.-C. Su, "Assessing finger joint biomechanics by applying equal
Limb Assisted with an Electromyography-Driven Neuromuscular force to flexor tendons in vitro using a novel simultaneous approach,"
Electrical Stimulation-Robotic Arm," Frontier in Neurology (Stroke), PLoS One, vol. 11, no. 8, 2016.
2017. [23] C. Metcalf, S. Notley, C. Paul, J. Burridge and V. Yule, "Validation
[4] Grimaldi G and Manto M., "Functional impacts of exoskeleton-based and application of a computational model for wrist and hand
rehabilitation in chronic stroke: multi-joint versus single-joint robotic movements using surface markers," IEEE Transaction on biomedical
training.," J Neuroeng Rehabil , vol. 1, no. 10, p. 113, 2013. engineering, vol. 55, no. 3, pp. 1199-1210, 2008.
[5] Sandy McCombe Waller, Jill Whitall, Toye Jenkins, Laurence S [24] Dong Hyun Kim, Si-Hwan Heo and Hyung-Soon Park, "Biomimetic
Magder, Daniel F Hanley, Daniel F Hanley and Andreas R Luft, Finger Extension Mechanism for Soft Wearable Hand," in
"Sequencing bilateral and unilateral task-oriented training versus task International Conference on Rehabilitation Robotics (ICORR),
oriented training alone to improve arm function in individuals with London, 2017.
chronic stroke," bmc neurology, vol. 236, no. 14, 2014. [25] S. Ueki, "Development of a Hand-Assist Robot With Multi-Degrees-
[6] C. N. Schabowsky, S. B. Godfrey and R. J. Holley, P. , of-Freedom for Rehabilitation Therapy," IEEE/ASME Transactions
"Development and pilot testing of HEXORR: Hand EXOskeleton on Mechatronics, pp. 136-146, Feb 2012.
Rehabilitation Robot," Journal of NeuroEngineering and [26] N. Bhatt and V. SKM, "Posture similarity index: a method to
Rehabilitation, vol. 7, no. 1, p. 36, 2010. compare hand postures in synergy space," Peerj, vol. 6, no. e6078,
[7] A. Wege and G. Hommel, "Development and control of a hand 2018.
exoskeleton for rehabilitation of hand injuries," 2005 IEEE/RSJ [27] World Health Organization (WHO), 19 November 2013. [Online].
International Conference on Intelligent Robots and Systems,, pp. Available: https://www.who.int/news-room/fact-sheets/detail/spinal-
3046-3051, 2005. cord-injury.
[8] L. Gerez, J. Chen and M. Liarokapis, "On the development of [28] Raghavan P., "Upper limb motor impairment after stroke.," Phys Med
adaptive, Tendon-Driven, wearable exo-glove for grasping Rehabil Clin N Am, vol. 4, no. 26, p. 599–610, 2015.
capabilities enhancement," IEEE Robotics and Automation letters,
2018.
[9] S. W. Lee, K. A. Landers and H. S. Park, "Development of a
biomimetic hand exotendon device (BiomHED) for restoration of
functional hand movement post-stroke," IEEE Trans Neural Syst
Rehabil Eng, vol. 22, no. 4, pp. 886-98, 2014.
[10] Rita M. Patterson and Chia-Ye Chu , "Soft robotic devices for hand
rehabilitation and assistance: a narrative review," Journal of
NeuroEngineering and Rehabilitation, vol. 15, no. 9, 2018.
[11] Dmitry Popov, Igor Gaponov, and Jee-Hwan Ryu, "Portable
Exoskeleton Glove With Soft Structure," IEEE/ASME Transaction on
Mechatronics, pp. 865-875, 2017.
[12] M. Nilsson, "The Soft Extra Muscle System for Improving the
Grasping Capability in Neurological Rehabilitation.," IEEE/EMBS
International Conference on Biomedical, pp. 412-417, 2012.
[13] Pilwon Heo, Gu Gwang Min, Soo-jin Lee and Kyehan Rhee,
"Current hand exoskeleton technologies for rehabilitation and
assistive engineering," International Journal of Precision
Engineering and Manufacturing 13 (5), p. 807–824., 2012.
[14] H. In, B. Kang, M. Sin, and K.-J. Cho, "Exo-glove: A wearable robot
for the hand with a soft tendon routing system," IEEE Robot. Autom.
Mag., pp. 97-105, 2015.
[15] J. Leijnse, P. Quesada and C. Spoor, "Kinematic evaluation of the
finger's interphalangeal joints coupling mechanism-variability,
flexion-extension differences, triggers, locking swanneck deformities,
anthropometric correlations.," Journal of biomechanics, vol. 43, pp.
2381-2393, 2010.
[16] J. Leijnse and C. Spoor, "Reverse engineering finger extensor
apparatus morphology from measured coupled interphalangeal joint
angle trajectories - a generic 2D Kinematic model.," Journal of
biomechanics , vol. 45, pp. 569-578, 2012.
[17] A. Nimbarte, R. Kaz and Z.-M. Li, "Finger joint motion generated by
individual extrinsic muscles: A cadaveric study," Journal of
orthopaedic surgery and research, vol. 3, no. 27, 2008.
[18] K. p. a. W. d. Koos jaap van zwieten, "An analytical expression for
the D.I.P.–P.I.P. flexion interdependence in human fingers.," Acta of
Bioengineering and Biomechanics, vol. 17, no. 1, 2015.
[19] F. Netter, Atlas of human anatomy.
[20] Kuo PH, Deshpande AD, "Muscle-tendon units provide limited
contributions to the passive stiffness of the index finger
metacarpophalangeal joint.," Journal of Biomechanics, vol. 45, no.
15, 2012.
[21] D. Neumann, Kinesiology of the Musculoskeletal System, 2009.

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