U.S. patent application number 13/644815 was filed with the patent office on 2013-01-31 for robotic rehabilitation apparatus and method.
This patent application is currently assigned to REHABTEK LLC. The applicant listed for this patent is Rehabtek LLC. Invention is credited to Yupeng Ren, Li-Qun Zhang.
Application Number | 20130030327 13/644815 |
Document ID | / |
Family ID | 39690827 |
Filed Date | 2013-01-31 |
United States Patent
Application |
20130030327 |
Kind Code |
A1 |
Zhang; Li-Qun ; et
al. |
January 31, 2013 |
Robotic Rehabilitation Apparatus and Method
Abstract
This patent describes an 8+2 degrees of freedom (DOF)
intelligent rehabilitation robot capable of controlling the
shoulder, elbow, wrist and fingers individually and allowing
functional arm movements with accompanying trunk and scapular
motions. The rehabilitation robot uses the following integrated
rehabilitation approach: 1) it has unique diagnostic capabilities
to determine patient-specific multiple joint and/or multiple DOF
biomechanical and neuromuscular changes; 2) it stretches the stiff
joints/DOFs under intelligent control to loosen up the specific
stiff joints and to reduce excessive cross-coupling
torques/movements between the specific joints/DOFs, which can be
done based on the above diagnosis for subject-specific treatment;
3) the patients practice voluntary reaching and some functional
tasks to regain/improve their motor control capability, which can
be done after the stretching loosened up the stiff joints; and 4)
the outcome will be evaluated quantitatively at the levels of
individual joints, multiple joints/DOFs, and the whole arm.
Inventors: |
Zhang; Li-Qun; (Wilmette,
IL) ; Ren; Yupeng; (Chicago, IL) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Rehabtek LLC; |
Wilmette |
IL |
US |
|
|
Assignee: |
REHABTEK LLC
Wilmette
IL
|
Family ID: |
39690827 |
Appl. No.: |
13/644815 |
Filed: |
October 4, 2012 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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12527389 |
Aug 14, 2009 |
8317730 |
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PCT/US08/54148 |
Feb 15, 2008 |
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13644815 |
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Current U.S.
Class: |
600/587 ;
601/5 |
Current CPC
Class: |
A61H 2201/1676 20130101;
A61H 2201/1215 20130101; A61H 2201/5007 20130101; A61H 1/0237
20130101; A61H 1/0288 20130101; A61H 1/0285 20130101; A61H
2201/5061 20130101; A61H 2201/1659 20130101; A61H 1/0274 20130101;
A61H 2201/1638 20130101; A61H 1/0281 20130101; A61H 2201/163
20130101; A61H 2201/0192 20130101; A61F 5/0102 20130101; A61H
2201/1642 20130101 |
Class at
Publication: |
600/587 ;
601/5 |
International
Class: |
A61B 5/103 20060101
A61B005/103; A61H 1/02 20060101 A61H001/02 |
Claims
1. A process comprising: providing a human interface machine that
comprises a first joint that includes a plurality of degrees of
freedom, a force/torque sensor positioned to measure the
force/torque of the plurality of degrees of freedom, and a motor
positioned to move the first joint about at least one of the
plurality of degrees of freedom, and a second joint that includes a
plurality of degrees of freedom, a force/torque sensor positioned
to measure the force/torque of the plurality of degrees of freedom,
and a motor positioned to move the second joint about at least one
of the plurality of degrees of freedom; actuating the first joint
about at least one degree of freedom, while measuring the
forces/torques applied to a patient's first joint, and while
measuring the forces/torques applied to a patient's second joint;
and actuating the second joint about at least one degree of
freedom, while measuring the forces/torques applied to a patient's
first joint, and while measuring the forces/torques applied to a
patient's second joint.
2. The process of claim 1 further comprising repeating the
actuation of the first joint and repeating the actuation of the
second joint.
3. The process of claim 1, wherein actuating the first joint
includes holding the second joint at a fixed position.
4. The process of claim 1, wherein actuating the second joint
includes holding the first joint at a fixed position.
5. The process of claim 1, wherein the human interface machine
includes a third joint that includes a plurality of degrees of
freedom, a force/torque sensor positioned to measure the
force/torque of the plurality of degrees of freedom, and a
plurality of motors positioned to move about at least two of the
plurality of degrees of freedom; wherein the first joint is
actuated about at least one degree of freedom while holding the
second joint and third joint at fixed positions, while measuring
the forces/torques applied to a patient's first joint, while
measuring the forces/torques applied to a patient's second joint,
and while measuring the forces/torques applied to a patient's third
joint; and wherein the second joint is actuated about at least one
degree of freedom while holding the first joint and third joint at
fixed positions, while measuring the forces/torques applied to a
patient's first joint, while measuring the forces/torques applied
to a patient's second joint, and while measuring the forces/torques
applied to a patient's third joint.
6. The process of claim 5 further comprising: actuating the third
joint about at least one degree of freedom while holding the first
joint and second joint at fixed positions, while measuring the
forces/torques applied to a patient's first joint, while measuring
the forces/torques applied to a patient's second joint, and while
measuring the forces/torques applied to a patient's third
joint.
7. The process of claim 6, wherein the first joint is a wrist
joint; wherein the second joint is an elbow joint; and where in the
third joint is a shoulder joint.
8. The process of claim 1, wherein the first and second joints are
actuated by the motors.
9. A process comprising: executing a multi-joint/multi-degree of
freedom diagnosis that includes positioning a patient in a human
interface machine that includes an arm brace having a temporary
attachment element adapted to temporarily attach a human arm; the
arm brace disposed to move with the human arm while attached and
jointed such that an arm joint can move through a first degree of
freedom and at least one other degree of freedom; an elbow joint
affixed to the upper arm length adjustment including an elbow motor
and an elbow force/torque sensor; a forearm length adjustment
affixed to the elbow joint; a wrist and hand part affixed to the
forearm length adjustment including a supination/pronation motor, a
wrist flexion/extension motor, and a wrist force/torque sensor; the
plurality of sensors in operative communication with the arm brace
such that at least one sensor senses a first force/torque when an
arm joint is driven in a first degree of freedom and such that the
same sensor senses a second force/torque when the arm joint is
driven in a second degree of freedom; and a processor in operative
communication with the plurality of sensors and the plurality of
motors, the processor configured to calculate a coupling
relationship between a movement in the first degree of freedom and
the second force/torque sensed in the second degree of freedom, the
processor further configured to drive the arm joint through a first
degree of motion; actuating at least one motor to move a first
joint through a first degree of freedom while holding the other
joints at their initial positions and measuring the force/torque
and angular perturbations of all joints; and then repeating the
actuation and measurements for the remaining joints and degrees of
freedom.
10. The process of claim 9 further comprising executing a passive
stretching treatment that includes moving one joint of the patient
in the human interface machine until a pre-specified resistance
torque is reached.
11. The process of claim 10, wherein the passive stretching
includes holding the other joints at their positions.
12. The process of claim 9 further comprising executing a voluntary
movement training that includes providing a first target position
for the patient to achieve, optionally providing assistance or
resistance during the voluntary movement training, and providing a
second target position when the patient achieves the first target
position.
13. A process comprising: positioning a patient in a human
interface device; determining patient-specific multiple joint
and/or multiple degrees-of-freedom biomechanical and neuromuscular
changes by determining off-diagonal elements of [B.sub.ij] and
[K.sub.ij] matrices by multi-joint and multi-degree of freedom
analysis, thereby determining patient-specific flexibility, loss of
joint individuation, joint stiffness, and degree-or-freedom;
stretching the patient's stiff joints and degrees-of-freedom loss
to loosen up the stiff joints, increase the degrees-of-freedom, and
reduce excessive cross-coupling torques and movements between the
specific joints and degrees-of-freedom; directing the patient
through voluntary reaching and/or functional tasks to
regain/improve the patient's flexibility, focusing on the specific
joints, loss of joint individuation, and degrees of freedom with
movement impairment as determined by biomechanical and
neuromuscular changes; and recording quantitative changes in the
patient's joints.
14. The process of claim 13, wherein the human interface device has
horizontal abductions of a 60.degree. for the shoulder, 60.degree.
for the elbow flexion, 25.degree. for the wrist flexion and
60.degree. for the forearm supination.
15. The process of claim 13, wherein determining patient-specific
multiple joint and/or multiple degrees-of-freedom biomechanical and
neuromuscular changes comprises: actuating the patient's shoulder
by horizontal shoulder adduction/abduction while the patient's
elbow and wrist are free to move, and measure the coupled elbow and
wrist movement to evaluation loss of individuation; and actuating
the patient's shoulder by horizontal shoulder adduction/abduction
while the patient's elbow and wrist are held in a fixed position,
and measure the coupled elbow and wrist joint torques to evaluation
loss of individuation;
16. The process of claim 13, wherein determining patient-specific
multiple joint and/or multiple degrees-of-freedom biomechanical and
neuromuscular changes comprises: actuating the patient's wrist by
wrist flexion/extension while the patient's elbow and shoulder are
free to move and measure the coupled elbow and shoulder movement to
evaluation loss of individuation; and actuating the patient's wrist
by wrist flexion/extension while the patient's elbow and shoulder
are held in a fixed position and measure the coupled elbow and
shoulder joint torque to evaluation loss of individuation;
17. The process of claim 13, wherein determining patient-specific
multiple joint and/or multiple degrees-of-freedom biomechanical and
neuromuscular changes comprises: actuating the patient's forearm by
forearm supination/pronation while the patient's wrist, elbow and
shoulder are free to move, and measure the coupled motions at the
wrist, elbow and shoulder to evaluate loss of individuation; and
actuating the patient's forearm by forearm supination/pronation
while the patient's wrist, elbow and shoulder are held in a fixed
position, and measure the coupled wrist, elbow and shoulder joint
torque to evaluation loss of individuation.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This disclosure is a Continuation of U.S. patent application
Ser. No. 12/527,389 filed Aug. 14, 2009, the disclosure of which is
incorporated herein in its entirety.
BACKGROUND and FIELD OF THE INVENTION
[0002] The present invention relates to a device for diagnosing,
exercising, training, and evaluating human limbs. More
specifically, to a robotic device that allows rehabilitation
including precise diagnosis throughout the workspace of the limbs,
stretching a limb under intelligent control, training the limb
movement through voluntary exercises, and performing outcome
evaluation.
[0003] Spasticity, contracture, muscle weakness, and motor
impairment are commonly seen following stroke. The several symptoms
are closely related to each other and are major factors
contributing to disabilities in patients post stroke. The
hypertonus and reflex hyperexcitability disrupt the remaining
functional use of muscles, impede motion, and may cause painful
muscle spasms. Loss of muscle control, weakening and fatiguing of
muscles, lack of appropriate joint movement, prolonged spasticity
and associated painful muscle spasms may be accompanied by
structural changes of muscle fibers and connective tissue, which
may result in a reduction in joint range of motion (ROM) and lead
to a clinical contracture, joint deformity, and motor
impairment.
[0004] Several stereotypical patterns of limb deformity with
multiple joints involved are commonly seen in patients with
neurological impairments, including adducted/internally rotated
shoulder, flexed elbow, pronated forearm, flexed wrist, clenched
fist, foot drop, and abnormal gait motion. There is a strong need
to treat the deformed/hypertonic limbs and multiple involved joints
simultaneously on a frequent basis to reduce spasticity/contracture
and increase mobility.
[0005] For most patients post stroke, physical therapy is the
cornerstone of the rehabilitation process. Physical therapy is
important and effective in treating persons with
hypertonic/deformed limbs. A physical therapist uses physical
modalities, functional training, exercises, and one-on-one manual
manipulation of the stroke patient's body with the intent of
reducing spasticity and contracture and restoring movement
function. However, the effects may not be long lasting, partly due
to the limited and sometime infrequent therapy a patient can
receive. Practically, the manual stretching is laborious and the
outcome is dependent on the experience and subjective "end feeling"
of the therapists. For both the patients and therapists, there is a
need for a device that can stretch and mobilize the joints
precisely, reliably, and effectively.
[0006] For effective treatment, it is very important to accurately
diagnose limb impairments at multiple joints and multiple degree of
freedom (DOF) at each joint (e.g., shoulder horizontal
abduction/adduction, flexion/extension, and upper arm axial
rotation at the shoulder). Motor impairments in patients post
stroke affect the multiple joints of the limb simultaneously. In
terms of joint biomechanical properties, patients may develop
spastic hypertonia and reduced ROM at multiple joints with abnormal
coupling among the joints and with multiple DOFs at each joint. In
terms of voluntary control, patients post stroke may loose
independent movements of individual joints and coordination among
the joints. There is a strong need to diagnose the multi-joint/DOF
pathological changes and then treat the joints in well coordinated
ways. However, it is not practical for a clinician to evaluate the
increased resistance and abnormal couplings at the multiple joints
and multi-DOFs simultaneously and quantitatively. More accurate and
comprehensive diagnosis/evaluation is needed using a novel robotic
device and use the information obtained to guide subsequent
treatment/training.
[0007] A number of rehabilitation robotic devices have been used to
exercise the involved joints and reduce joint
spasticity/contractures. See, U.S. Pat. No. 6,599,255 B2. For
example, the continuous passive motion (CPM) device is widely used
in clinics and in patients' home to move a joint within a
pre-specified movement range, to prevent postoperative adhesion and
reduce joint stiffness. Advanced robot-aided devices have also been
developed to evaluate limb impairment quantitatively, and to assist
and guide patient's hand to reach a target in the limb workspace to
enhance neurorehabilitation following brain injury. However,
existing devices like the CPM machine move the limb at a constant
speed between two preset joint positions. When it is set within the
flexile part of the ROM, the passive movement does not usually
stretch into the extreme positions where contracture/spasticity is
significant. On the other hand, setting a CPM machine too
aggressively may risk injuring the joint because the machine
controls the joint position or velocity without incorporating the
resistance torque generated by the soft tissues. There is a need
for a device that can safely stretch the joint(s) to the extreme
positions with accurate control of the resistance torque and
stretching velocity. Furthermore, there is a need to follow up the
strenuous passive stretching with training of active movement and
to evaluate the impairment and rehabilitation outcome
quantitatively and objectively.
SUMMARY
[0008] The invention is a new intelligent rehabilitation robot
capable of controlling all joints simultaneously, which help to
achieve effective stroke rehabilitation based on the following
features incorporated: 1) it has unique diagnostic capabilities for
individual patients including information on which joints and which
DOFs are impaired, what are the abnormal couplings, and whether the
problem is due to passive muscle properties or active control
capabilities; 2) based on the diagnosis, it stretches the
hypertonic/deformed limb of the patients post stroke under
intelligent control to loosen up the specific stiff joint(s) or to
break up abnormal couplings between joints/DOFs so that the CNS can
potentially control the relevant muscles and limb movement more
effectively; 3) with the stiff joints loosed up, the patients
perform voluntary exercise to regain/improve their motor control
capability; 4) the outcome is evaluated quantitatively at the
levels of individual joints, multiple joints/DOFs, and the whole
limbs.
[0009] The present invention satisfies the need for the therapy of
limbs with impairment through a multi-step integrated
rehabilitation approach: diagnosing neuromuscular and biomechanical
impairments in limb functions, performing physical therapy
including passive stretching and voluntary movement exercises, and
evaluating the outcome quantitatively (FIG. 1).
[0010] The present invention further satisfies the need for a limb
and joint therapeutic device that is precise and accurate.
Furthermore, the invention satisfies the need for a device that can
stretch the limb or joint(s) under intelligent control and allow
the human subject move his/her limb freely or help the movement
with assistance.
[0011] Finally, the device satisfies the need for quantitative and
objective measurements of the impairments in terms of the
biomechanical and neuromuscular changes for diagnosis and outcome
evaluations.
[0012] According to the embodiments of the present invention, there
is a limb and joint therapeutic device for use by both clinicians
and patients, whether at home or at a clinic. The limb and joint
therapeutic device has a limb support, the limb support securing a
limb such that the limb is rotatable with respect to a joint. The
device has motors and motor shafts, the motors and shafts rotating
the joints at a variable velocity. A controller controls the
velocity or resistance torque in different control modes. In the
intelligent stretching mode, the controller controls the stretching
velocity at each joint based on the joint resistance torque
measurement. In the active exercise mode, the controller controls
the multiple joints involved based on the diagnosis by the device
and/or by the clinician.
[0013] The above advantages, features and aspects of the present
invention are readily apparent from the following detailed
description, appended claims and accompanying drawings.
[0014] Further areas of applicability of the present invention will
become apparent from the detailed description provided hereinafter.
It should be understood that the detailed description and specific
examples, while indicating the preferred embodiment of the
invention, are intended for purposes of illustration only and are
not intended to limit the scope of the invention.
BRIEF DESCRIPTION OF THE DRAWINGS
[0015] The present invention will become more fully understood from
the detailed description and the accompanying drawings,
wherein:
[0016] FIG. 1 is a flowchart describing the multi-step integrated
rehabilitation program proposed in the invention.
[0017] FIG. 2 shows the Robotic Apparatuses designed to diagnose,
treat with both passive stretching and active functional movements,
and evaluate multi-joint and multi-DOF biomechanical and
neuromuscular changes in patients with limb impairments.
[0018] FIG. 3 is the mechanical design of the x-y-z motion.
[0019] FIG. 4 is the mechanical design of the shoulder joint.
[0020] FIG. 5 is the mechanical design of the elbow joint.
[0021] FIG. 6 is the mechanical design of the wrist and hand
part.
[0022] FIG. 7 is the graph presenting couplings between the
shoulder and elbow, showing loss of independent control of an
individual joint (called loss of individuation), with data
collected using a 4-DOF arm rehabilitation robot. (a) Coupled elbow
flexion/extension when the subject attempted to move his/her
shoulder voluntarily in horizontal adduction. The subjects were
asked to do horizontal adduction/abduction and the elbow and wrist
were free to move. Marked elbow movement was seen in the patients
post stroke, suggesting loss of individuation. Data were from a
healthy subject (Control) and patients post stroke with mild
(Subject I) and severe (Subject II) impairment. (b) A similar
shoulder horizontal adduction task performed by the same three
subjects but with the elbow and wrist held at their initial
positions. Considerable coupling torque was seen at the elbow in
the patients post stroke, in the directions consistent with the
corresponding elbow joint movement in (a).
[0023] FIG. 8 is the graph showing biomechanical couplings between
the shoulder and elbow and the loss of independent control of
individual joints, with the data collected using a 4-DOF arm
rehabilitation robot. EMG signals from selected muscles and
cross-coupling torques at the elbow and wrist during the shoulder
horizontal abduction movement task is shown in FIG. 3(b). Notice
that the considerable coactivation of biceps and flexor carpi
radialis (FCR, a wrist flexor in the forearm) muscles during the
active shoulder horizontal abduction.
[0024] FIG. 9 shows the biomechanical couplings between the wrist
and elbow flexion, with data collected with the 4-DOF arm rehab
robot. (a) Couplings between the wrist and elbow flexion, with data
collected with the 4-DOF arm rehab robot. The subject was asked to
flex and extend the wrist throughout its ROM with the other joints
held at the initial position. Data were from a healthy subject
(Control) and patients post stroke with mild (Subject I) and severe
(Subject II) impairment. Notice that the patient with severe
impairment (Subject II) could not move her wrist. (b) Coupled elbow
flexion torque when the subjects attempted to twist his/her forearm
voluntarily. The subject was asked to supinate and pronate the
forearm throughout its ROM with the other joints held at the
initial position. Substantial coupling torque was seen at the elbow
flexion axis. Data were from a healthy subject (Control) and
patients post stroke with mild (Subject I) and severe (Subject II)
impairment.
[0025] FIG. 10 is the active workspace of voluntary reaching
movement in the horizontal plane and in the corresponding joint
space, with data collected with the 4-DOF arm rehab robot. Data
were from a healthy subject (Control) and 4 patients post stroke
with various degrees of impairment. The focus of the testing was on
the reaching and arm extension directions instead of the flexed
positions.
[0026] FIG. 11 is the active workspace of reaching in the joint
space, with data collected with the 4-DOF arm rehabilitation robot.
Data were from a healthy subject (Control) and 4 patients post
stroke with various degrees of impairment. The focus of the testing
was on the reaching and arm extension directions instead of the
flexed positions.
[0027] FIG. 12. is the data collected during stretching while the
shoulder was stretched during horizontal abduction movement at a
relatively low level of peak resistance torque (about .+-.3 Nm).
Joint torques at the shoulder, elbow and wrist during the shoulder
stretching from a healthy subject (a) and a patient post stroke
with considerable arm hypertonia/deformity (b and c) are shown. For
the patient, joint torques from similar stretching trials at the
beginning and end of the stretching session are shown in (b) and
(c), respectively.
[0028] FIG. 13 shows the shoulder, elbow and wrist passive ROMs
(passive workspace) from a patient post stroke with considerable
arm hypertonia/deformity. (a) The shoulder, elbow and wrist passive
ROMs (passive workspace) from a patient post stroke with
considerable arm hypertonia/deformity, determined using the 4-DOF
arm rehab robot and shown in 3-D joint space. (b) Stretching data
from a stroke patient with substantial hypertonia/deformity at the
elbow and wrist. The elbow and wrist of a stroke patient with arm
deformity and hypertonia were stretched simultaneously using the
Robotic apparatus. The left and right columns correspond to data
from the elbow and wrist, respectively. The 1st and 2nd rows show
the elbow and wrist flexion angles and elbow and wrist flexion
torque (elbow and wrist flexor resistance torque was negative) as
functions of time. The 3rd row shows the torque-angle curve at the
two joints and the slope of the curves corresponds to the joint
stiffness. The blue dashed line and red solid line correspond to
data at the beginning and end of a stretching session,
respectively.
[0029] FIG. 14 is the experimental data during voluntary wrist
extension before (left column) and after (right column) the
stretching treatment with reduced flexor-extensor
cocontraction.
[0030] FIG. 15 is the screen shot of the hand reaching exercise
software designed to improve voluntary movement control. The hand
reaching exercise designed to improve voluntary motor control. The
shoulder, elbow and wrist angles are displayed in real-time
(represented by the three circles). The subject is asked to move
the hand from the current position (the circle with hashed lines)
to the target (the star) by placing the circle around the star,
while keeping the shoulder, elbow and wrist angles matched as well.
Audio cue is used to indicate a successful target match. The dashed
curve shows the trajectory of the hand movement. Some DOFs of the
arm are fixed for simplicity.
[0031] FIG. 16 is a graphic display of a cross joint torque-angle
relationship. The elbow id moved by the robot with the wrist joint
held by the robot. The cross-joint stiffness K32 is evaluated as
the slope of the loading phase of the curve relating the wrist
flexion torque to the elbow flexion angle.
[0032] FIG. 17 is a graphic display of stiffness matric. Diagonal
and off-diagonal elements of stiffness matrix [K] from 7 stroke
survivors and 3 healthy subjects. Subscripts 1, 2 and 3 correspond
to the shoulder, elbow and wrist, respectively. The standard
deviation bars are only shown in one direction for clarity.
[0033] FIG. 18 is a graphic display of a motor status S over. (a)
Loss of individuation characterized by the peak coupled torque at
the elbow (flexioniextension) when the subject tried to move the
shoulder isolately in horizontal abduction. S1, S2, S3 and S4
represent four stroke survivors. (b) The corresponding motor status
score of the four stroke survivors, which is negatively related to
the cross-joint couplings.
COMPONENT LIST
[0034] 12 Vertical Disp. Actuator [0035] 14 Shoulder Flexion Motor
[0036] 16 Shoulder Horizontal Abduction Motor [0037] 18 Shoulder
Platform (X, Y, Z Displacement) [0038] 20 Shoulder Horizontal
Abduction [0039] 22 Arm Rotation [0040] 24 Circular Guide [0041] 26
Forearm Supination [0042] 28 Wrist Flexion [0043] 30 MCP Finger
Flexion [0044] 32 Hand strap [0045] 34 Finger Motor [0046] 36
Finger Torque Sensor [0047] 38 Wrist multi-axis force sensor [0048]
40 Wrist Motor [0049] 42 Forearm Length Adjustment [0050] 44
Supination Motor [0051] 46 Elbow Motor [0052] 48 Elbow Multi-Axis
Force Sensor [0053] 50 Elbow Flexion [0054] 52 Arm Length
Adjustment [0055] 54 Arm rotation motor [0056] 56 Shoulder
multi-axis force sensor [0057] 58 Shoulder Flexion [0058] 60
Vertical Guide [0059] 62 Horizontal X-Y Guides [0060] 64 Linear
Actuator for vertical motion (Z direction) [0061] 66 Supporter for
Gravity Compensation [0062] 68 Linear Motion Guide in Vertical
Direction [0063] 70 Glenohumeral Joint [0064] 72 X-Y motion [0065]
74 Z direction (Scapular Elevation/Depression) [0066] 76 Motor for
Shoulder H. Ab/Adduction [0067] 78 Motor for Shoulder
Flexion/Extension [0068] 80 Cable for driving Shoulder Flexion
[0069] 82 Cable for driving Shoulder Int./Ext. Rotation [0070] 84
Circular guide for shoulder Int./Ext. Rotation [0071] 86 Motor for
Shoulder Int./Ext. Rotation [0072] 88 6DOF Force/Torque sensor
[0073] 90 Pulley for changing direction of cable tension [0074] 92
Shoulder Horizontal Link [0075] 94 Cable Tensioners [0076] 96 Shaft
1A [0077] 98 Shaft 1B [0078] 100 Shaft 2A [0079] 102 Shaft 2B
[0080] 104 Drum 2 [0081] 106 Drum 1 [0082] 108 Motor for Elbow
Flexion/Extension [0083] 110 6 DOF force/torque Sensor [0084] 112
Circular Guide [0085] 114 Forearm links [0086] 116 Motor for
Forearm Sup./Pron. [0087] 118 Cable driving Forearm Sup./Pron.
[0088] 120 Drum 2 [0089] 122 Drum 1 [0090] 124 Cable driving elbow
joint [0091] 126 Cable Tensioner [0092] 128 Shaft 1B [0093] 130
Shaft 1A [0094] 132 6 DOF force/torque sensor [0095] 134 Motor for
hand opening/closing [0096] 136 Two bar linkage [0097] 138 Torque
sensor for MCP joint [0098] 140 Cable driven bevel gear [0099] 142
Motor for wrist flexion/extension
DETAILED DESCRIPTION
[0100] The following description of the preferred embodiment(s) is
merely exemplary in nature and is in no way intended to limit the
invention, its application, or uses.
[0101] Embodiments of the invention provide techniques for robotic
rehabilitation using the four-step integrated protocol including
multi-joint/multi-DOF diagnosis, intelligent passive stretching,
voluntary movement training, and outcome evaluation.
[0102] A. Patient-specific diagnosis of the passive and active
biomechanical changes at the joints in the limbs.
[0103] In the passive mode, the multi-joint device moves the joints
of the impaired limb throughout the ROMs both simultaneously and
individually under precise control with the multi-axis torques and
positions measured at the joints simultaneously. In the active
mode, the patient is asked to move the impaired joints individually
and the multiple joints of the limb simultaneously for functional
movements such as reaching and walking, with the multi-joint and
multi-DOF dynamic properties measured at every joint
simultaneously. Multi-joint and multi-DOF analysis is done on the
data from the passive and active movements to diagnose the
multi-joint biomechanical changes in the impaired limb during
certain tasks, which is directly useful in guiding rehabilitation
of the impaired limb in the subsequent aims.
[0104] A.1 Robotic Apparatus Designed to Diagnose
Multi-Joint/Multi-DOF Biomechanical Changes
[0105] A custom-developed unique robotic apparatus is used to
diagnose the biomechanical changes and abnormal couplings at the
joints of the impaired limb of patients post stroke (FIG. 2).
[0106] For the upper limb, the shoulder, elbow and wrist are
controlled in 8 active DOFs individually by 8 servomotors plus 2
passive DOFs, which is important in natural functional arm
movements (FIG. 2a). For the lower limb, hip, knee and ankle are
controlled in 3 active DOFs individually by 3 servomotors (FIG.
2b).
[0107] FIG. 2. The Robotic Apparatus designed to diagnose, treat
with both passive stretching and active functional movements, and
evaluate multi-joint and multi-DOF biomechanical changes including
the upper limb (a) and lower limb (b).
[0108] For the upper limb, the robotic arm is mounted on an X-Y-Z
table with the vertical Z-axis driven by a linear actuator and free
to slide passively in the X-Y directions (FIG. 3). The whole device
is mounted on the X-Y-Z table so that the glenohumeral joint can
move in X-Y-Z directions to follow the scapular motion and trunk
motion. Linear motion guides are used for the guiding in all three
directions. Considering arm elevation involves both glenohumeral
and scapular elevations and thus the glenohumeral joint moves in
the vertical plane, the linear actuator controlling in the vertical
direction and the free sliding in the mediolateral direction helps
keep the robotic arm aligned with the glenohumeral joint.
Furthermore, considering stroke survivors often use trunk leaning
to compensate for their reaching motion, the robotic arm is free to
slide in the anteroposterior direction to avoid unnatural
restraints (FIG. 3). Weight supporting mechanism is used for
reducing the size of the linear actuator because the mechanism
supports most of the weight from the apparatus and the subject's
limb.
[0109] The glenohumeral joint is controlled actively in 3 DOFs:
horizontal abduction/adduction, flexion/extension, and
internal/external rotation (FIG. 4). Two motors for shoulder
horizontal abduction/adduction and flexion/extension are located
behind the subject and remotely drive the joint through cable
mechanism. For the shoulder Horizontal Ab/Adduction, two cables are
affixed to Shaft 1A and Shaft 1B wrapping in the opposite
directions. The other ends of the two cables (dark red color) are
affixed to Drum 1 with each cable wrapping in the opposite
direction. The cables are tensioned tight using the cable tensioner
composed of worm gear. Drum 1 is fixed to the shoulder horizontal
link and moves the linkage. In the similar way, two cables (blue
color) wrap around Shaft 2A and Shaft 2B to drive shoulder
Flexion/Extension and the cables are affixed to Drum 2. From the
bottom of Drum 2, another two cables drives the shoulder
flexion/extension through pulleys to another two drums aligned with
shoulder flexion/extension joint (yellow and green drums). The
flexion/extension joint has two stages for the cable mechanism.
Pulleys were used to change the direction of cable tension. The
shoulder internal/external joint was driven by using circular guide
on which the link is mounted. The motor travels around the joint
with the link as the motor drives the joint through cable
mechanism. A 6 DOF force/torque sensor is mounted between two links
so that it measures the 3 forces (Fx, Fy, Fz) and 3 moments (Mx,
My, Mz).
[0110] FIG. 3. Mechanical design for X-Y-Z motion.
[0111] FIG. 4. Mechanical Design of Shoulder Joint
[0112] At the elbow, the motor remotely drives the elbow
flexion/extension joint through cable (FIG. 5) with the cable
tensioner displayed in the figure. In this way, the motor driving
the elbow joint can be placed along the linkage to save rooms under
the robot. Without saving the rooms, the motor will take space
under the robot and will hit the subject's body during the
operation. Two cables wrap around Shaft 1A and Shaft 1B
respectively and are fixed to Drum 1. Cable tensioner (worm gear)
tightens the cables so that the elbow motor can drive the elbow
joint without backlash. Patients post stroke often develop
pronation deformity of the forearm, it is important to move and
evaluate the forearm in a proper range of pronation. The forearm is
mounted to a circular guide through a forearm brace (not shown in
the figure for clarity) and controlled by a servomotor through a
cable-driven mechanism, which allows controlled movement of forearm
supination-pronation (FIG. 5). Two cables wrap around Drum 2 and
are fixed to the two ends of the circular guide. As the motor
rotates, the motor and the forearm links rotate around the circular
guide creating motions for forearm supination and pronation.
[0113] FIG. 5. Mechanical design of the elbow joint.
[0114] The wrist is driven in flexion/extension by the wrist motor
(FIG. 6). Wrist motor is located orthogonal to the wrist joint
using bevel gear to save the rooms under the robot. A 6 DOF
force/torque sensor measures forces and torques at the wrist joint.
Patients post stroke often develop clinched first and it is
important to stretch their fingers to open the hand. Two-bar
linkage driven by a motor selected for hand open/close while a
torque sensor at MCP (metacarpophalangeal) joint measures the
torques at the joint. Adjustable braces (not shown in the figure
for clarity) hold the hand securely.
[0115] FIG. 6. Mechanical design of wrist and hand part.
[0116] To diagnose arm impairment in terms of multi-joint
biomechanical properties, it is important to move the arm
throughout its range of motion. In order to have anatomic range of
motion at each joint, each joint in the robotic apparatus has the
sufficient range of motion (Table 1). Direct driving of each
joint/DOF at its axis using a servomotor provides large
physiological ranges of motion at the shoulder, elbow, forearm and
wrist (FIG. 2a), which is important in the multi-joint and
multi-DOF diagnosis.
TABLE-US-00001 TABLE 1 Range of Motion of the robot ROM in ROM (the
robotic Joint ADL tasks apparatus) Shoulder H. Abd/Add 120 deg 135
deg Shoulder Flex/Ext 110 deg 110 deg Shoulder Int/Ext Rotation 135
deg 135 deg Shoulder Vertical 150 mm 200 mm Displacement (due to
scapular motion) Elbow Flex/Ext 120 deg 130 deg Forearm 150 deg 150
deg Supination/Pronation Wrist Flexion/Extension 115 deg 150
deg
[0117] Six-axis resistance torques/forces are measured at each of
the joints including the shoulder, elbow and wrist (FIG. 2a). Each
of the 8 DOFs plus the 2 passive DOFs is measured by encoders built
in the servomotors or potentiometers mounted on the X-Y-Z table.
The comprehensive kinetic and kinematic measurements allow us to
evaluate the increased stiffness, abnormal couplings among the
multiple joints and multi-DOFs, and loss of individuation to
diagnose the pathological changes difficult to do in a manual
examination by a clinician.
[0118] A.2 Diagnosis of Biomechanical Changes in the Impaired
Arm
[0119] The subject sits upright comfortably on a sturdy barber's
chair, with the trunk strapped to the backrest. The arm, forearm
and hand are strapped to their corresponding braces, with the
relevant axes of the apparatus aligned with the arm at the
shoulder, elbow, and wrist (FIG. 2a). The position of the elbow and
wrist servomotors can be adjusted along the arm and forearm for
different arm and forearm lengths.
[0120] In diagnosing the multi-joint and multi-DOF biomechanical
changes, the robotic apparatus operates in both passive and active
modes. In the passive mode, the apparatus moves the joints of
patients post stroke throughout the ROMs both simultaneously and
individually in well-controlled patterns with the multi-axis
torques and positions measured at all joints simultaneously. In the
active mode, the patient moves the impaired limb voluntarily and
the multi-joint and multi-DOF dynamic properties are measured at
the all joints simultaneously.
[0121] Multi-joint and multi-DOF analysis is done on data from the
Robotic apparatus to diagnose the multi-joint biomechanical changes
in the impaired arm and evaluate the Robotic apparatus. For
example, which joints and DOFs are coupled abnormally? What are the
patterns of the abnormal coupling or coactivation? Which joints are
stiff? Among the many possible measures, the ROM, stiffness at the
shoulder, elbow and wrist, and coupling torques between the three
joints are analyzed.
[0122] Loss of individuation can be evaluated through multi-joint
and multi-DOF analysis. When a subject was asked to do horizontal
adduction/abduction of the shoulder without moving the elbow and
wrist, for example, a healthy subject could do that successfully
(see the blue curve in FIG. 7a), while patients post stroke
produced considerable coupled elbow flexion/extension movement.
Furthermore, different patients could have different abnormal
couplings. On the one hand, the patient with severe impairment
(with the stereotypical pattern of adducted shoulder, flexed elbow,
flexed wrist and clenched fist, and with control of the shoulder
but not the elbow and wrist) showed coupled elbow flexion during
shoulder horizontal abduction, indicating stiff elbow flexor
muscles. On the other hand, the patient with mild impairment
generated elbow extension during shoulder horizontal abduction,
suggesting abnormal coactivation of the elbow extensor muscles
during the shoulder horizontal abduction. The coupled elbow motion
during shoulder horizontal adduction was confirmed by the
corresponding elbow flexion torque in a similar task of shoulder
horizontal adduction but with the elbow flexion fixed by the
Robotic apparatus (FIG. 7b). Furthermore, during passive movement
of the shoulder in horizontal adduction, similar coupling torque
was generated in elbow flexion. However, the torque amplitude
(.about.1.8 Nm, not shown here) was much lower than that in FIG. 7b
(.about.14 Nm, the green line), indicating the abnormal
coactivation of the elbow flexors (biceps and maybe others as well)
during shoulder horizontal abduction was a more significant factor
contributing to the coupled elbow torque/motion than the passive
stiffness of the elbow flexors. Coactivation of the biceps was
corroborated with EMG measurement (FIG. 8). Based on the diagnosis,
the different patterns of abnormal couplings should be treated
differently in the subsequent passive stretching and active
movement therapy. For analysis abnormal coupling, the peak coupling
torque is used.
[0123] FIG. 7 Couplings between the shoulder and elbow, showing
loss of individuation, with data collected with the 4-DOF arm rehab
robot. (a) Coupled elbow flexion/extension when the subject
attempted to move his/her shoulder voluntarily in horizontal
adduction. The subjects were asked to do horizontal
adduction/abduction and the elbow and wrist were free to move.
Marked elbow movement was seen in the patients post stroke,
suggesting loss of individuation. Data were from a healthy subject
(Control) and patients post stroke with mild (Subject I) and severe
(Subject II) impairment. (b) A similar shoulder horizontal
adduction task performed by the same three subjects but with the
elbow and wrist held at their initial positions. Considerable
coupling torque was seen at the elbow in the patients post stroke,
in the directions consistent with the corresponding elbow joint
movement in (a).
[0124] FIG. 8. Couplings between the shoulder and elbow, showing
loss of individuation, with data collected with the 4-DOF arm rehab
robot. EMG signals from selected muscles and cross-coupling torques
at the elbow and wrist during the shoulder horizontal abduction
task shown in FIG. 7(b). Notice the considerable coactivation of
biceps and FCR during the active shoulder horizontal abduction.
[0125] Abnormal couplings can be similarly analyzed for the distal
joints. For example, when the subjects were asked to flex/extension
the wrist isolately without moving other joints, the healthy
subject (Control) could do so successfully, while the patient with
mild impairment generated substantial elbow flexion torque (Subject
I) and the patient with severe impairment (Subject II) could not
move the wrist and generated some torque at the elbow through its
coupling with the shoulder (FIG. 9a). Similarly, when the subjects
were asked to supinate/pronate the forearm with moving in other
joints, the healthy subject could do it successfully. The patient
with mild impairment showed substantial coupling torque about the
elbow flexion axis (Subject I) while the patient with sever
impairment could not control the forearm twisting (Subject II)
(FIG. 9b).
[0126] FIG. 9 (a) Couplings between the wrist and elbow flexion,
with data collected with the 4-DOF arm rehab robot. The subject was
asked to flex and extend the wrist throughout its ROM with the
other joints held at the initial position. Data were from a healthy
subject (Control) and patients post stroke with mild (Subject I)
and severe (Subject II) impairment. Notice that the patient with
severe impairment (Subject II) could not move her wrist. (b)
Coupled elbow flexion torque when the subjects attempted to twist
his/her forearm voluntarily. The subject was asked to supinate and
pronate the forearm throughout its ROM with the other joints held
at the initial position. Substantial coupling torque was seen at
the elbow flexion axis. Data were from a healthy subject (Control)
and patients post stroke with mild (Subject I) and severe (Subject
II) impairment.
[0127] The limited reaching workspace shown by the patients post
stroke (FIG. 10) can be analyzed further at the level of individual
joints (FIG. 11) for better understanding of the reduced workspace
and potentially guiding therapy. As shown, patients with different
degrees of impairment showed different amount of workspace
reduction (FIG. 10 and FIG. 11). The reduced workspace for
different patients may be due to different changes at the
individual joint level, some may be more due to restricted wrist
movement and some may be due to combination of the elbow and wrist
(FIG. 11). In the 3-D joint space (top-left plot in FIG. 11), the
patients had hard time to reach the extended positions. The
subject's reaching data are analyzed to determine the specific
joints contributing to the reduced workspace. Similar analysis is
done for the workspace during passive movement driven by the
Robotic apparatus.
[0128] FIG. 10. Active workspace of reaching in the horizontal
plane and at the corresponding joint space (see FIG. 11 below),
with data collected with the 4-DOF arm rehab robot. Data were from
a healthy subject (Control) and 4 patients post stroke with various
degrees of impairment. The focus of the testing was on the reaching
and arm extension directions instead of the flexed positions.
[0129] FIG. 11. Active workspace of reaching in the joint space,
with data collected with the 4-DOF arm rehab robot. Data were from
a healthy subject (Control) and 4 patients post stroke with various
degrees of impairment. The focus of the testing was on the reaching
and arm extension directions instead of the flexed positions.
[0130] B. Passive stretching of all joints of the impaired limb
strenuously and safely under intelligent control based on the above
diagnosis to reduce hypertonia and abnormal coupling at the joints
involved.
[0131] From the robotic diagnosis, the joints (and DOFs) with
excessive coupling and/or increased stiffness and the associated
limb postures are identified, the robotic apparatus stretches all
the joints simultaneously in general between the curled (flexed)
limb positions and extended limb positions. We also focus more on
the joints/DOFs which need to be loosened up based on the above
individual diagnosis. The robotic apparatus is under novel
multi-joint intelligent control to stretch the joints forcefully
and safely in well-coordinately patterns. On the one hand, for safe
treatment, the stretching velocities decreases with increasing
resistance torques at the multiple joints involved and each joint
is stretched according to its own condition and the conditions of
the coupled joints. On the other hand, for effective treatment, the
stretching does not stop until pre-specified peak resistance
torques are reached at the joints involved (and at individual
DOFs). The stretched limb is held at the extreme positions for a
period of time to let stress relaxation occur before the joints are
moved to other extreme positions.
[0132] B.1 Stretch Multiple Joints/Multi-DOFs under Intelligent
Control
[0133] The joints in the impaired limb with deformity/hypertonia in
patients post stroke are stretched forcefully and safely under
intelligent control to loosen up the stiff muscles and joints (FIG.
2). The subject is seated upright comfortably on a barber chair,
with the trunk strapped to the backrest. The segments in limbs are
strapped to the apparatus through braces, respectively. Mechanical
clamps are used to fix any of the braces to the robotic apparatus
more securely.
[0134] The robotic apparatus is driven by multiple servomotors
controlled by a digital controller, which can either drive all or
several the joints/DOFs simultaneously or drive a joint
individually. Based on the diagnosis, we know which joints are
stiff, coupled abnormally, and need to be loosened up. For each
servo system, the digital controller reads the joint position and
resisting torques and adjusts the stretching velocity
accordingly.
[0135] Based on a novel intelligent stretching strategy, the
digital controller controls the stretching velocity at each joint
according to the resistance torque as follows. Near the end of ROM,
the increasing resistance slows down the motor gradually, which is
critical for safe operation. Furthermore, the stretching does not
stop until a pre-specified peak resistance torque is reached. In
this way, the muscle-tendons involved are stretched strenuously and
safely, which likely results in a larger ROM. Once the specified
peak resistance torque is reached, the servomotor holds the joint
at the extreme position for a period of time (e.g., 5 sec during
each cycle of the back-and-forth stretching), as used by a
therapist. In the middle ROM where the resistance is usually low,
the motor stretches the slack muscles quickly at higher speeds. As
a safety precaution, position limits can be set by the operator and
they are monitored by the digital controller together with the
torque limits. Specifically, the following rules are implemented in
the digital controller to adjust the motor velocity V(t) every 0.5
msec:
V ( t ) = { 0 , if ( M res ( t ) .gtoreq. M p or .theta. ( t )
.gtoreq. .theta. p + .theta. d ) and need to hold - V max , if ( M
res ( t ) .gtoreq. M p or .theta. ( t ) .gtoreq. .theta. p +
.theta. d ) and have held long enough max ( C M res ( t ) , V min )
, if 0 < M res ( t ) < M p min ( C M res ( t ) , - V min ) ,
if - M p < M res ( t ) < 0 V max , if ( M res ( t ) .ltoreq.
- M n or .theta. ( t ) .ltoreq. .theta. n - .theta. d ) and have
held long enough 0 , if ( M res ( t ) .ltoreq. - M n or .theta. ( t
) .ltoreq. .theta. n - .theta. d ) and need to hold ( 1 )
##EQU00001##
where .theta.(t) and M.sub.res(t) are the joint position and
resistance torque at time t, respectively. M.sub.p and M.sub.n are
the specified peak resistance torque at the positive and negative
ends of the joint ROM, respectively (both are positive numbers).
V.sub.min and V.sub.max (positive numbers) are the magnitudes of
the lowest (for stretching in the joint extreme positions) and
highest speed (for stretching in the mid-ROM), respectively. C is a
constant, scaling the 1/M.sub.res(t) to the appropriate stretching
velocity. .theta.p and .theta..sub.n are the specified positive and
negative end of the ROM, respectively. .theta..sub.d (a
non-negative number) represents the allowed further rotation beyond
the position limits (to leave room for stretching-induced
improvement in ROM). If .theta..sub.d is chosen to be a very large
number (to allow the device move beyond the position limits) or if
.theta..sub.p and .theta.n are set outside the ROM, the stretching
control is dominated by the resistance torque (the stretching is
still safe) and the motor reverses its rotation once the specific
resistance torque is reached for the specified amount of time. On
the other hand, if M.sub.p and M.sub.n are chose to be very large,
the stretching is restricted by the position limits. In general, we
want the stretching reaches the torque limits at both ends of the
ROM with the position limits incorporated into the control scheme
as a safety measure and as an optional mode of stretching,
therefore the .theta..sub.p and .theta..sub.n are set to
approximately match the ROM by manually pushing the joint to its
extreme positions (or by entering their values through the
keyboard) and the .theta..sub.d is chosen as a positive number
(e.g., 5.degree.). In this way, the torque limits are reached most
of the time, while the position limits still restrict potential
excessive joint movement. All the control parameters can be
adjusted conveniently within pre-specified ranges.
[0136] The digital controller checks the joint position and torque
signals 2000 times per second and will shut down the system if they
are out of pre-specified ranges. Mechanical and electrical stops
can be used to restrict the motor range of motion. The operator and
the patient each have a stop switch, and either of them can shut
down the apparatus by pressing the switch.
[0137] B.2 Control of Multiple Joints Coordinately
[0138] Considering that there are dozens of muscles and other soft
tissues crossing the shoulder, elbow, and wrist joints or hip,
knee, and ankle joints and some crossing two joints, movement and
control of the joints are closely coupled. Furthermore, the
couplings may be increased considerably in hypertonic and deformed
limbs of patients post stroke. For more effective treatment of
hypertonic limb, all the joints should be treated together in a
well-coordinated way. Considering the limb deformity is
characterized with adducted and internally rotated shoulder, flexed
elbow and wrist and pronated forearm, and hypertonia may exist in
both extension and flexion ends of the joints, the shoulder, elbow,
and wrist joints are stretched simultaneously by the apparatus
between overall whole arm stretched out and curled in
positions.
[0139] There are infinite numbers of possible control modes during
the stretching. In the 7-D joint space with 7-DOF active control at
the shoulder, elbow and wrist, there are infinite number of paths
between the whole arm curled position to the whole arm stretched
position. The specific control mode or hand path is dependent on
the ROMs and stretching speed at the shoulder, elbow, and wrist.
The multiple joints and DOFs are stretched following the several
rules:
[0140] Start with a neutral position with shoulder at 60.degree.
abduction and 30.degree. flexion, elbow at 60.degree. flexion,
wrist at 25.degree. flexion, and forearm at the 60.degree.
supination. If the patient's arm cannot be put at the posture
comfortably, the closest position is used.
[0141] Stretch the shoulder into abduction/extension/external
rotation, elbow and wrist into extension, and forearm into
supination simultaneously under intelligent control with specified
the peak resistance torques and with the stretching velocity
decreased with increasing resistance, as described above for
individual joints/DOFs (Eq. (1)).
[0142] When one joint or DOF reaches the extreme
extended/abducted/externally rotated/supinated position, hold it at
the extreme position and wait for the other joints/DOFs to reach
their extreme positions as well. As these other joints are being
stretched to reach their peak resistance torque (or position)
limit, the resistance torque at the first joint(s) which already
reaches the torque limit may go beyond the torque limit due to
coupling between the joints/DOFs. If the extra torque beyond the
specified limit is within a pre-specified range (e.g., 1.5 Nm), the
first joint(s) is kept at the held position. Otherwise, the first
joint(s) is moved back a bit until the resistance torque is back at
the torque limit.
[0143] Once all the joints/DOFs reach the extreme
extension/supination, hold the arm at the posture for a period of
time (e.g., 5 seconds) to let stress relaxation occur and the stiff
joints become more compliant.
[0144] The arm is moved back towards the initial neutral position
and it is held there for a period of time (e.g., 1 sec.), which
provides us a measure of arm biomechanical properties at the common
position in the stretching process.
[0145] Next, the arm is stretched towards the whole arm curled
(adducted, internally rotated, flexed and pronated) extreme
position. The stretching is controlled similarly as in the case of
stretching into extended/abducted/externally rotated/supinated
extreme positions.
[0146] The back and forth stretching process is repeated until a
pre-specified stretching period (e.g., 10 minutes) is reached or a
stop switch is pushed.
[0147] The operator may adjust the stretching limits and stretch at
more strenuous levels.
[0148] For pilot data, stretching has been done successfully under
intelligent control on patients post stroke with arm hypertonia and
stereotypical deformity. Simultaneous shoulder, elbow and wrist
stretching is used as treatment to loosen up the stiff
muscles-joints of the arms with hypertonia/deformity, while
isolated shoulder, elbow or wrist passive movement is used to
evaluate the multi-joint dynamics including couplings among the
joints.
[0149] When the shoulder is stretched back and forth in horizontal
abduction with the elbow and wrist held at constant positions,
there is a considerable flexion toque generated at the elbow and
wrist, following roughly the pattern of the shoulder torque,
probably related to the stiff arm muscles crossing the joints (FIG.
12). Compared with healthy subject, the hypertonic arm of the
patient post stroke produced several fold higher coupling torques
at the elbow and wrist joints (FIG. 12). Furthermore, after
strenuous stretching of shoulder, elbow and wrist joints
simultaneously for about 30 min, the coupling torques at the elbow
and wrist when the shoulder is stretched are reduced considerably
(FIGS. 12b and c).
[0150] FIG. 12. The shoulder was stretched in horizontal abduction
at low torque level (about .+-.3 Nm) using the 4-DOF arm rehab
robot. Joint torques at the shoulder, elbow and wrist during the
shoulder stretching from a healthy subject (a) and a patient post
stroke with considerable arm hypertonia/deformity (b and c) are
shown. For the patient, joint torques from similar stretching
trials at the beginning and end of the stretching session are shown
in (b) and (c), respectively.
[0151] Stretching-induced improvement can be analyzed and shown
clearly in 3-D joint space, with the shoulder, elbow and wrist
stretched simultaneously (FIG. 13a). For further detail during the
stretching including the stretching-induced improvement, the
kinematic and kinetic data can also be shown together as function
of time (FIG. 13b). The Robotic apparatus stretched arms with
hypertonia/deformity strenuously and safely, and patients post
stroke like the stretching and feel it loosen their stiff arms.
Some relevant analysis results are given here. For examples, paired
t-test showed that both the elbow extension (P=0.01) and flexion
(P=0.03) ROMs measured at controlled resistance were improved
significantly after the strenuous stretching. With the same
subjects, wrist extension also increased significantly with P=0.002
(paired t-test). Wrist flexion did not change considering that the
wrists were hypertonic and deformed in flexion.
[0152] The strenuous and yet safe stretching loosen the stiff
joints and make them significantly less stiff. At comparable joint
positions, both elbow extension (P=0.005) and flexion (P=0.042)
stiffness are reduced after a session of strenuous stretching.
Wrist joint stiffness is also reduced significantly in both
extension (P=0.024) and flexion (P=0.044) (paired t-test).
[0153] FIG. 13. (a) The shoulder, elbow and wrist passive ROMs
(passive workspace) from a patient post stroke with considerable
arm hypertonia/deformity, determined using the 4-DOF arm rehab
robot and shown in 3-D joint space. (b) Stretching data from a
stroke patient with substantial hypertonia/deformity at the elbow
and wrist. The elbow and wrist of a stroke patient with arm
deformity and hypertonia were stretched simultaneously using the
Robotic apparatus. The left and right columns correspond to data
from the elbow and wrist, respectively. The 1.sup.st and 2.sup.nd
rows show the elbow and wrist flexion angles and elbow and wrist
flexion torque (elbow and wrist flexor resistance torque was
negative) as functions of time. The 3rd row shows the torque-angle
curve at the two joints and the slope of the curves corresponds to
the joint stiffness. The blue dashed line and red solid line
correspond to data at the beginning and end of a stretching
session, respectively.
[0154] With the strenuous stretching loosening up the stiff joints,
the CNS may be able to control the muscles and move the joint more
properly. During the active wrist extension, a patient with
difficulty extending the wrist voluntarily (left column of FIG. 14)
could control it more easily and moved it further into wrist
extension after stretching (right column of FIG. 14). The
improvement may be due to reduced co-contraction of wrist flexors
as well as improved control of the wrist extensors. The
flexor/extensor co-contraction ratio during the extension task was
reduced from 29.6% to 20.0% (FIG. 14). Wrist extension MVC of the
subject was similarly improved, partly due to the reduction in
co-contraction.
[0155] FIG. 14. Voluntary wrist extension before (left column) and
after (right column) stretching with reduced flexor-extensor
cocontraction.
[0156] C. Voluntary movement training after the passive stretching
loosens the stiff muscles.
[0157] Motor impairment is associated with both neural and
peripheral biomechanical changes. After the intelligent stretching
reduces the abnormal joint coupling and stiffness, the neural
command may be able to better control the muscles and move the arm.
The robotic apparatus is controlled back-drivable so that patients
can move the limb with the apparatus freely to match or track
targets displayed on a computer screen during the movement
training. The movement training is done in the form of computer
games to motivate the patients and enhance the motor relearning
(FIG. 15).
[0158] FIG. 15. The hand reaching exercise designed to improve
voluntary motor control. The shoulder, elbow and wrist angles are
displayed in real-time (represented by the brown, blue and red
circles, respectively). The subject is asked to move the hand from
the current position (the green circle) to the target (the red dot)
by placing the green circle around the red dot, while keeping the
shoulder, elbow and wrist angles matched as well. Audio cue is used
to indicate a successful target match. The target in left figure
represents a flexed arm position, while the one on the right
corresponds to an extended arm position. The light red line shows
the trajectory of the hand movement. Some DOFs of the arm are fixed
for simplicity.
[0159] With the workspace in the horizontal plane determined by
diagnosis for an individual patient in the diagnosis, a number of
target points in the workspace can be displayed and the patient is
asked to move the hand from the current position to the target,
while matching the individual joint angles as well. A circle in the
virtual hand needs to overlap the red-dot target on the computer
monitor for a successful match (FIG. 15). Assistance (or
resistance) can be provided by the apparatus to the impaired arm
during the voluntary movement training when needed. Once a target
is reached, it becomes the new current position and a new target in
the workspace is displayed for the subject to move to form the new
current position (FIG. 15). The shoulder external rotation,
flexion, forearm supination can be fixed for simplicity but they
can be represented in the figure and matched by the subject if
needed). The patients perform the voluntary exercise for about 20
minutes.
[0160] For potential further development, as the patient progresses
in motor control capability, the workspace is increased and
resistance instead of assistance may be provided during the
movement to make it more challenging to the patients.
[0161] D. To evaluate the outcome in terms of the biomechanical
properties and motor-control ability induced by the passive
stretching and active movement exercise at the multiple joints
involved, including the passive range of motion (ROM) and stiffness
at each joint, passive arm ROM, coupling torques/stiffness between
the joints/DOFs, active ROM at each joint and coupled movement at
the other joints, hand reaching workspace, reaching accuracy and
velocity, and muscle strength at each joints and coupled torques at
other joints.
[0162] D.1. Procedure
[0163] For evaluation of the stretching and active movement
treatments, a number of biomechanical measures are obtained.
[0164] The subject sits upright with the shoulder, elbow and wrist
axes aligned with the corresponding motor and long axis of the
forearm concentric with the supination circular guide (FIG. 1). The
initial position is 60.degree. horizontal adduction for the
shoulder, and 60.degree., 25.degree. and 60.degree. for the elbow
flexion, wrist flexion, and forearm supination, respectively (FIG.
1).
[0165] At the beginning and end of the treatment, passive
stretching is done at matched low terminal torques and slow
velocity to evaluate the passive ROM (a direct measure of
contracture) and stiffness of each of the joints (shoulder
horizontal abduction, elbow and wrist flexion), and cross coupling
torques between the shoulder, elbow and wrist. Moving into joint
extreme positions manifests the passive mechanical changes in
muscles-joints, while the very slow speed controlled by the
servomotor minimizes reflex contributions. Reversing the rotation
at a common resistance torque level allows objective and accurate
comparisons between before and after stretching. The robot moves
one of the joints slowly until a pre-specified resistance torque is
reached at this target joint while holding the other joints at
their initial positions. Joint angle and multi-axis torques are
recorded at the shoulder, elbow and wrist joints simultaneously.
The same test is repeated without holding the other joints. The
procedure is repeated for each of the multi-joints and
multi-DOFs.
[0166] Identifying Dynamics of a Limb with Multiple Joints/DOFs
[0167] Multi-joint and multi-DOF dynamics of the human arm can be
described quantitatively using the rehabilitation robot and the
system parameters evaluated can be used for the diagnosis and
evaluations described in this invention. The dynamics of arm with
the shoulder, elbow and wrist moving in the horizontal plane will
be used as an example and described in detail below. As the
shoulder, elbow and wrist are controlled by the robot and rotate in
the horizontal plane with three DOFs, the relationships between the
shoulder, elbow and wrist torques (system inputs) and the shoulder,
elbow and wrist angles (system outputs) can be derived through
Lagrange-Euler or Newton-Euler formulations. The torques about the
vertical axes at the shoulder, elbow and wrist are composed of the
inertial, viscous, elastic, Coriolis, and centripetal components.
Considering the total torques at each joint are summations of the
individual torque components, three-joint dynamics can be described
as:
[ I 11 I 12 I 13 I 21 I 22 I 23 I 31 I 32 I 33 ] [ .DELTA. .phi. 1
( t ) .DELTA. .phi. 2 ( t ) .DELTA. .phi. 3 ( t ) ] + [ B 11 B 12 B
13 B 21 B 22 B 23 B 31 B 32 B 33 ] [ .DELTA. .phi. . 1 ( t )
.DELTA. .phi. . 2 ( t ) .DELTA. .phi. . 3 ( t ) ] + [ K 11 K 12 K
13 K 21 K 22 K 23 K 31 K 32 K 33 ] [ .DELTA..phi. 1 ( t )
.DELTA..phi. 2 ( t ) .DELTA..phi. 3 ( t ) ] + [ C 11 C 12 C 13 C 14
C 15 C 16 C 21 C 22 C 23 C 24 C 25 C 26 C 31 C 32 C 33 C 34 C 35 C
36 ] [ .DELTA. .phi. . 1 2 ( t ) .DELTA. .phi. . 2 2 ( t ) .DELTA.
.phi. . 3 2 ( t ) .DELTA. .phi. . 1 ( t ) .DELTA. .phi. . 2 ( t )
.DELTA. .phi. . 1 ( t ) .DELTA. .phi. . 3 ( t ) .DELTA. .phi. . 2 (
t ) .DELTA. .phi. . 3 ( t ) ] T = [ .DELTA. T 1 ( t ) .DELTA. T 2 (
t ) .DELTA. T 3 ( t ) ] + [ .xi. 1 ( t ) .xi. 2 ( t ) .xi. 3 ( t )
] ( 2 ) ##EQU00002##
where .DELTA.T.sub.1(t), .DELTA.T.sub.2(t), and .DELTA.T.sub.3(t)
are the measured shoulder, elbow and wrist torque perturbations
respectively, .DELTA..phi..sub.1(t), .DELTA..phi..sub.2(t), and
.DELTA..phi..sub.3(t) are the angular perturbations of the
shoulder, elbow and wrist, respectively. .xi..sub.1(t),
.xi..sub.2(t), and .xi..sub.3(t) are the modeling errors. Matrices
[I.sub.ij], [B.sub.ij] and [K.sub.ij] represent the inertial,
viscous and elastic properties, respectively. The left and right
halves of [C.sub.ij] describe the nonlinear centripetal and
Coriolis effects, respectively. Notice that the Coriolis and
centripetal torques are only part of the coupling torques between
the two joints. The I, B, and K matrices also characterize
couplings between the joints. When the evaluation is done around an
operating state, parameters such as I.sub.11 and K.sub.22 can be
regarded as constants.
[0168] From the system dynamics, simplifications can be made in Eq.
(1) considering that C.sub.34=2C.sub.32,
C.sub.25=C.sub.26=-2C.sub.32, C.sub.23=-C.sub.32,
C.sub.12=-C.sub.21, C.sub.13=-C.sub.31,
C.sub.16=C.sub.15=2C.sub.13=-2C.sub.31,
C.sub.14=2C.sub.12=-2C.sub.21 and that the inertia matrix
I.sub.3.times.3 is symmetric. Therefore, Eq. (2) can be simplified
as:
[ I 11 I 21 I 31 I 21 I 22 I 32 I 31 I 32 I 33 ] [ .DELTA. .phi. 1
( t ) .DELTA. .phi. 2 ( t ) .DELTA. .phi. 3 ( t ) ] + [ B 11 B 12 B
13 B 21 B 22 B 23 B 31 B 32 B 33 ] [ .DELTA. .phi. . 1 ( t )
.DELTA. .phi. . 2 ( t ) .DELTA. .phi. . 3 ( t ) ] + [ K 11 K 12 K
13 K 21 K 22 K 23 K 31 K 32 K 33 ] [ .DELTA..phi. 1 ( t )
.DELTA..phi. 2 ( t ) .DELTA..phi. 3 ( t ) ] + [ 0 - C 21 - C 31 - 2
C 21 - 2 C 31 - 2 C 31 C 21 0 - C 32 0 - 2 C 32 - 2 C 32 C 31 C 32
0 2 C 32 0 0 ] [ .DELTA. .phi. . 1 2 ( t ) .DELTA. .phi. . 2 2 ( t
) .DELTA. .phi. . 3 2 ( t ) .DELTA. .phi. . 1 ( t ) .DELTA. .phi. .
2 ( t ) .DELTA. .phi. . 1 ( t ) .DELTA. .phi. . 3 ( t ) .DELTA.
.phi. . 2 ( t ) .DELTA. .phi. . 3 ( t ) ] T = [ .DELTA. T 1 ( t )
.DELTA. T 2 ( t ) .DELTA. T 3 ( t ) ] + [ .xi. 1 ( t ) .xi. 2 ( t )
.xi. 3 ( t ) ] ( 3 ) ##EQU00003##
[0169] The off-diagonal elements of the [B.sub.ij] and [K.sub.ij]
matrices characterize the viscous and elastic cross-couplings
between the joints, which may be changed significantly by the
impairment and will be evaluated to diagnose abnormal
cross-couplings in the impaired arm.
[0170] Although the system dynamics in Eq. (2) is very complex, an
innovative procedure is used here to decompose the complex and
almost intractable system to single-joint level, which can then be
solved with well-established methods.
[0171] Eq. (2) above provides a comprehensive characterization of
the multi-joint biomechanical properties, such as the cross
couplings characterized by the off-diagonal elements of the
stiffness matrix [K] and diagonal elements characterize the local
stiffness of each individual joint (shoulder, elbow, wrist).
Evaluations based on stiffness matrix [K] and viscosity matrix [B]
will be valuable in evaluating the impairment and in guiding the
rehabilitation.
[0172] However, even with simplification, the nonlinear multi-input
multi-output system in Eq. (3) still has 27 parameters and is very
difficult to identify reliably. The following systematic procedure
is developed to identify this complex system (and other complex
systems with even more joints/DOFs involved) robustly.
[0173] 1. When the shoulder joint is perturbed by the robot with
the elbow and wrist held at fixed positions, .phi..sub.2(t) and
.theta..sub.3(t) are constant;
.DELTA..phi..sub.2(t)=.DELTA..phi..sub.3(t)=.DELTA.{dot over
(.phi.)}.sub.2(t)=.DELTA.{dot over (.phi.)}.sub.3=.DELTA.{umlaut
over (.phi.)}.sub.2(t)=.DELTA.{umlaut over (.phi.)}.sub.3 (t)=0.
The first to third rows of Eq. (3) are reduced to Eq. (3) to (5),
respectively. T.sub.11(t), T.sub.21(t) and T.sub.31 (t) represent
the shoulder, elbow and wrist torques measured in this case,
respectively (.DELTA.T.sub.11(t), .DELTA.T.sub.21(t) and
.DELTA.T.sub.31(t) correspond to their changes from the initial
values). At the shoulder joint,
I.sub.11.DELTA.{umlaut over (.phi.)}.sub.1(t)+B.sub.11.DELTA.{dot
over
(.phi.)}.sub.1(t)+K.sub.11.DELTA..phi..sub.1(t)=.DELTA.T.sub.11(t)
(4)
[0174] Parameters I.sub.11, B.sub.11 and K.sub.11 (shoulder
inertia, viscosity and stiffness respectively) can be estimated
from Eq. (4).
[0175] For the elbow joint, the elbow joint torque induced by
perturbation at the shoulder gives
I.sub.21.DELTA.{umlaut over (.phi.)}.sub.1(t)+B.sub.21.DELTA.{dot
over
(.phi.)}.sub.1(t)+K.sub.21.DELTA..phi..sub.1(t)=C.sub.21.DELTA.{umlaut
over (.phi.)}.sub.1.sup.2(t)=.DELTA.T.sub.21(t) (5)
[0176] Parameters I.sub.21, B.sub.21, K.sub.21 and C.sub.21 can be
estimated from the above equation. Note that the off-axis terms
B.sub.21 and K.sub.21 are non-zero due to the viscoelastic coupling
between the joints. B.sub.21 and K.sub.21 give the viscous and
elastic cross-couplings from the shoulder perturbation to the
coupled elbow torque, respectively.
[0177] For the wrist joint, the wrist joint torque induced by
perturbation at the shoulder gives
I.sub.31.DELTA.{umlaut over (.phi.)}.sub.1(t)+B.sub.31.DELTA.{dot
over
(.phi.)}.sub.1(t)+K.sub.31.DELTA..phi..sub.1(t)=C.sub.31.DELTA.{umlaut
over (.phi.)}.sub.1.sup.2(t)=.DELTA.T.sub.31(t) (6)
[0178] Parameters I.sub.31, B.sub.31, K.sub.31, and C.sub.31 can be
estimated from the above equation. Similarly, B.sub.31 and K.sub.31
are non-zero due to the viscoelastic coupling between the joints.
B.sub.31 and K.sub.31 give the viscous and elastic cross-couplings
from the shoulder perturbation to the coupled wrist torque,
respectively.
[0179] 2. When the elbow joint is perturbed with the shoulder and
wrist held at fixed positions, .phi..sub.1(t) and .phi..sub.3(t)
are constant;
.DELTA..phi..sub.1(t)=.DELTA..phi..sub.3(t)=.DELTA.{dot over
(.phi.)}.sub.1(t)=.DELTA.{dot over (.phi.)}.sub.3(t)=.DELTA.{umlaut
over (.phi.)}.sub.1(t)=.DELTA.{umlaut over (.phi.)}.sub.3(t)=0. The
first to third rows of Eq. (3) are reduced to Eq. (7) to (9),
respectively. T.sub.12(t), T.sub.22(t) and T.sub.32(t) represent
the shoulder, elbow and wrist torques in this case, respectively.
At the shoulder joint,
I.sub.12.DELTA.{umlaut over (.phi.)}.sub.2(t)+B.sub.12.DELTA.{dot
over
(.phi.)}.sub.2(t)+K.sub.12.DELTA..phi..sub.2(t)=C.sub.12.DELTA.{umlaut
over (.phi.)}.sub.2.sup.2(t)=.DELTA.T.sub.12(t) (7)
[0180] Parameters I.sub.12, B.sub.12, K.sub.12, and C.sub.12 can be
estimated from the above equation. Notice that since
I.sub.12=I.sub.21, as an option, we can estimate I.sub.12 from Eq.
(5) and substitute it here in Eq. (7) as known for simplification.
Similarly, since C.sub.12=-C.sub.21, C.sub.12 can be estimated from
Eq. (5) and taken as known here. B.sub.12 and K.sub.12 give the
viscous and elastic cross-couplings from the elbow perturbation to
the coupled shoulder torque, respectively.
[0181] For the elbow joint, the elbow joint torque induced by
perturbation at the elbow gives
I.sub.22.DELTA.{umlaut over (.psi.)}.sub.2(t)+B.sub.22.DELTA.{dot
over (.psi.)}.sub.2(t)+K.sub.22.DELTA..psi..sub.1(t)=T.sub.22(t)
(8)
[0182] Parameters I22, B22 and K22 can be estimated from the above
equation.
[0183] For the wrist joint, the wrist joint torque induced by
perturbation at the elbow gives
I.sub.32.DELTA.{umlaut over (.phi.)}.sub.2(t)+B.sub.32.DELTA.{dot
over
(.phi.)}.sub.2(t)+K.sub.32.DELTA..phi..sub.2(t)=C.sub.32.DELTA.{umlaut
over (.phi.)}.sub.2.sup.2(t)=.DELTA.T.sub.32(t) (9)
[0184] Parameters I.sub.32, B.sub.32, K.sub.32, and C.sub.32 can be
estimated from the above equation. B.sub.32 and K.sub.32 give the
viscous and elastic cross-couplings from the elbow perturbation to
the coupled wrist torque, respectively.
[0185] An example of estimating parameters of the
multi-joint/multi-DOF system dynamics is given here.
[0186] To evaluate the multi-joint biomechanical changes post
stroke, elements of the stiffness [K.sub.ij] matrix are determined
(see Eq. (2) and Eq. (3)) with the off-diagonal elements
characterizing the cross-coupling stiffness between the joints and
the diagonal elements characterizing elastic stiffness local to the
individual joints. Similarly, the off-diagonal elements of the
[B.sub.ij] matrix are estimated for the cross-coupling viscous
components between joints and the diagonal elements for viscosity
local to the shoulder, elbow or wrist. The robotic arm moves an
individual joint selectively with the multi-axis torques and angles
measured at all the joints simultaneously. With the joint movement
well controlled by the robot, the [K.sub.ij] and [B.sub.ij] can be
estimated quantitatively based on above equations (one equation at
a time so the complex system is reduced to the single-joint
level).
[0187] The multi-joint/multi-DOF stiffness matrix K can be
determined quantitatively using the rehabilitation robot. For
example, K.sub.32 in Eq. (9) can be determined as the slope of
curve between the wrist torque and elbow angle when the elbow is
moved by the rehabilitation robot with the wrist locked by the
robot and torque measured (FIG. 16). The stiffness matrix K for the
passive shoulder-elbow-wrist joints is determined from multiple
stroke survivors and multiple healthy subjects using the robot arm.
Stroke survivors showed not only much increased stiffness at the
shoulder, elbow and wrist locally but also much higher cross
couplings among the joints (FIG. 17).
[0188] The controller disclosed above is either loaded with the
dynamics data structure above or may interface with the data
structure recorded in a machine readable format.
[0189] FIG. 16. Cross-joint torque-angle relationship. The elbow is
moved by the robot with the wrist joint held by the robot. The
cross-joint stiffness K.sub.32 is evaluated as the slope of the
loading phase of the curve relating the wrist flexion torque to the
elbow flexion angle.
[0190] FIG. 17. Diagonal and off-diagonal elements of stiffness
matrix [K] from 7 stroke survivors and 3 healthy subjects.
Subscripts 1, 2 and 3 correspond to the shoulder, elbow and wrist,
respectively. The standard deviation bars are only shown in one
direction for clarity.
[0191] Impairments during voluntary movement can also be quantified
by the rehabilitation robot, which can be used for the diagnosis
and outcome evaluations. Impairment in independent control of
individual joint (so-called loss of individuation) can be evaluated
quantitatively and systematically by analyzing the coupled
torque/movement at the other joints/DOFs when the subject is asked
to move a target joint selectively without moving the others. As an
example of characterization of loss of individuation, the coupled
elbow torque during shoulder horizontal abduction is shown in FIG.
18(a) for 4 stroke survivors and one healthy subject. The
corresponding motor status score (a measure of human arm motor
function) of the patients is shown in FIG. 18(b).
[0192] FIG. 18. (a) Loss of individuation characterized by the peak
coupled torque at the elbow (flexion/extension) when the subject
tried to move the shoulder isolately in horizontal abduction. S1,
S2, S3 and S4 represent four stroke survivors. (b) The
corresponding motor status score of the four stroke survivors,
which is negatively related to the cross-joint couplings.
[0193] As various modifications could be made to the exemplary
embodiments, as described above with reference to the corresponding
illustrations, without departing from the scope of the invention,
it is intended that all matter contained in the foregoing
description and shown in the accompanying drawings shall be
interpreted as illustrative rather than limiting. Thus, the breadth
and scope of the present invention should not be limited by any of
the above-described exemplary embodiments, but should be defined
only in accordance with the following claims appended hereto and
their equivalents.
* * * * *