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Proceedings of the ASME 2010 International Design Engineering Technical Conferences & Computers and Information in Engineering Conference IDETC/CIE 2010 August 15-18, 2010, Montreal, Quebec, Canada



Gul Kremer The Pennsylvania State University University Park, Pennsylvania, USA E-mail:

Volkan Patoglu Gurdal Ertek ∗ Ozgur Oz Deniz Zoroglu Faculty of Engineering and Natural Sciences Sabanci University Orhanli, Tuzla 34956, Istanbul, Turkey Email:

Appendix A: Literature and Research on Hand and Finger Exoskeletons A careful literature survey by the authors revealed that the majority of the literature reports the developed robots from a purely mechanical engineering point of view. In this group of studies, a brief description of the health problem is followed by a detailed description of the robot’s components and the mechanical working principles. A small percentage of these studies also report results from usability studies [1] [2], which are essential in the assessment of the developed robots. These studies collect data during the rehabilitation process through electronic data collection devices, compute movement performance measures, and then analyze whether the robot meets clinical assessment measures [3]. Even fewer studies are found to report findings from interviews and surveys carried out with the patients and health professionals. Yet, carrying out a survey before the usability study has the advantage of increasing the safety of the robot. [4] presents a recent review of the survey-based assessment studies in literature. The earliest studies with user surveys on rehabilitation robots are by Dijkers et al. [5] and Stanger et al. [6]. Dijkers et al. [5] combine data from usability tests and surveys with pa-

∗ Address

all correspondence to this author.

tients and therapists for assessing a robot for post-stroke rehabilitation. Their study suggests that “therapists can adjust quickly to working effectively with this type of sophisticated equipment.” Stanger et al. [6] review nine task priority surveys conducted in England and North America on rehabilitation robots. Four of the surveys are carried out prior to the development of the robot, whereas the five others are carried out after a prototype has been developed. Hammel [7] describes how robots developed at the Palo Alto Veterans Affairs Medical Center at Stanford University are assessed. The assessment process has three phases: Conceptual brainstorming, clinical feasibility testing, and viability testing (evaluation in everyday performance contexts). Muras et al. [8] survey only patients, identifying areas in which there is demand for assistive technologies. Lee et al. [9] survey the opinions of only therapists on rehabilitation robots, without introducing a specific robotic system. Coote and Stokes [10] and Holt et al. [4] survey both therapists and patients on an upper-limb rehabilitation robots. Our paper follows a data analysis approach similar to that of [4], distinguishing between quantitative and qualitative questions. In contrast to the mentioned studies, our paper focuses especially on the mechanical design of the robot, including detailed querying of its mechanisms, since the second group of respondents consists of engineers. The ASME paper describes the finger exoskeleton devel1

oped at Sabanci University. Other hand and finger exoskeletons have been developed at TU Berlin Department of Computer Science [11], Laboratory for Intelligent Mechanical Systems at Northwestern University [12], Department of AdvancedRobotics at Istituto Italiano di Tecnologia (IIT) [13], and School of Computing, Science and Engineering, University of Salford [14]. The hand/finger exoskeleton that has become the commercial standard is the CyberGrasp exoskeleton, which possesses a resistive force-reflecting system, and fits over a CyberGlove data glove [15].


5. Very important ... 1. Weakly important A03b∗ . How important is the ease of setup of the robot to you? 5. Very important ... 1. Weakly important A03c∗ . How important is the weight of the robot to you? 5. Very important ... 1. Weakly important A03d∗ . How important is the cost of the robot to you? 5. Very important ... 1. Weakly important A03e∗ . How important is the maintainability and ease of repair of the robot to you? 5. Very important ... 1. Weakly important

Appendix B: Quantitative Questions In this Appendix, all the quantitative questions and their answers are given For extended statistical analysis, the ordinal answers of most of the questions were linearly converted into interval scale, transforming the questions into quantitative ones. For each question, a subsequent bar chart displays the histogram of the answers. A01∗ .

A. B. C. D. E.

How much do you agree with the following statement? “Rehabilitation equipment can have great positive impact on the treatment process.” I definitely agree I agree I do not agree I definitely do not agree Undecided (considered as missing data)

A03f∗ . How important is the durability of the robot to you? 5. Very important ... 1. Weakly important FIGURE 1. A01∗ . POSITIVE IMPACT OF REHABILITATION EQUIPMENT ON THE TREATMENT PROCESS

A03g∗ . How important is the safety of the robot to you? 5. Very important ... 1. Weakly important

A02∗ .

A03h∗ .

How much do you agree with the following statement? “Finger exoskeleton can greatly speed up the treatment process.” A. I definitely agree B. I agree C. I do not agree D. I definitely do not agree E. Undecided (considered as missing data) A03a∗ . How important is the portability of the robot to you?

How important is the robot to have adjustable components to you? Very important

5. ... 1. Weakly important A03i∗ . How important is the comfortability of the robot to you? 5. Very important ... 1. Weakly important 2

A04∗ .

How important is the appearance (color, shape, aesthetics) of the robot for the patient? A. Very important B. Important C. Does not matter D. Not important

with the under-actuated design. However, this is not an important limitation, as the finger exoskeleton can perform several coordinated movements that are most relevant to several grasp types (power, pinch, etc). B01∗ . How much do you agree with the following statement? “It’s appropriate that the linkage design is underactuated.” A. I definitely agree B. I agree C. I do not agree


A05∗ . How important is the silent operation of the robot? A. Very important B. Important C. Does not matter D. Not important


B02∗ : Direct Drive & Capstan Mechanics: Direct drive actuation and a capstan mechanism with relatively low transmission ratio is used to ensure back-driveability of the robot. Back-drivability means, when something goes wrong, the power can be cut from the system, and it will be possible to move the un-powered device without any resistance. That is to say, an injured finger can move the device with experiencing least amount of resistance. A high transmission ratio increases the parasitic dynamics due to the actuator. A capstan transmission is preferred over gears due to its backlash free, low friction character. In force feedback devices, having a smooth transmission is important to reduce torque ripple.


B02∗ . How much do you agree with the usage of direct drive actuator and capstan drive (rather than actuator with gearbox)? A. Very suitable B. Suitable C. Not suitable D. No opinion (considered as missing data)

B01∗ : Under-actuated Linkage Design Mechanics: An under-actuated mechanism is preferable since it is low cost and low weight. However, most important reason for choosing an under-actuated design is the kinematics of the mechanism that is solely dictated by human finger. That is, the mechanism cannot force the human finger to do a motion that is not compatible with human finger. Given the fact that kinematics of each finger is different (due to link length, ligaments, etc), it would be much more difficult to ensure such a motion with a fully actuated system. An advantage of a fully actuated system is the fact that it can dictate concurrent motion of the phalanxes, while only sequential movements are possible

B03∗ : Linkage-based Design Mechanics: Linkage-based design has the advantage of transmitting larger forces/torques. This was the reason behind its selection for the prototype robot. More importantly, the forces can be transmitted directly to the phalanxes not the joints, ensuring a safe and comfortable coupling with the patient. 3




B. Partially appropriate C. Not appropriate D. Other (considered as qualitative comments) E. Unsure or no opinion (considered as missing data)

B03∗ . How much do you agree with the following statement? “Linkage-based design is more suitable (better) than cable-based design.” A. I definitely agree B. I agree C. I do not agree D. Other (considered as qualitative comments)



B07∗ . Is it appropriate to add an actuator (motor) that will enable the movement of the wrist? A. Yes B. No

B05∗ : Linkage Thickness Mechanics: Aluminum is selected since it is light but strong. Plastic needs to be too thick for the same strength. Carbon fiber is hard to process. Titanium us expensive. Thickness is decided such that when two exoskeletons are worn on two consequent fingers, they do not collide to each other. B05∗ . Each linkage is 2mm thick, and is produced with laser. Do you believe that this is an appropriate thickness? A. Appropriate B. Partially appropriate C. Not appropriate D. Unsure or no opinion (considered as missing data)


B06∗ . The robot is fixed on the wrist by a plastic component, to achieve stability. Is the current positioning of the robot appropriate? A. Appropriate

B07∗ .


C02a∗ . How important is the freedom of movement of the 4

5. ... 1.

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robot to you? Very important Weakly important

C02b∗ . How important is the tightness of the robot to you? 5. Very important ... 1. Weakly important

Extra gain from same actuator (1, 6%) Obtain powerful actuator (1, 6%) Pneumatic actuator (1, 6%) Redesign (1, 6%) Third phalanx exercise and redesign (1, 6%) With respect to usability and manufacturability, which materials would you suggest, other than aluminium? Aluminium (12, 71%) Carbon fiber (2, 12%) Hard plastic (2, 12%) Composite materials with plastic (1, 6%)

B08. ⋄ ⋄ ⋄ ⋄

C02c∗ . While the robot is used, what should be the angle of the arm with respect the ground? 180 Parallel to the ground ... 0. Perpendicular to the ground

Should the robot fix the wrist, or should it allow for the movement of the wrist? Fixed wrist (11, 75%) Flexible wrist (6, 35%)

B09. ⋄ ⋄

C04∗ . How important is the ergonomics of the robot? A. Very important B. Important C. Does not matter D. Not important

Which material is most appropriate for connecting the finder to the moving part of the robot? Vectro (12, 71%) Silicon (3, 18%) Elastic rag with filling (1, 6%) Plastic rag (1, 6%)

B10. ⋄ ⋄ ⋄ ⋄

C08∗ .

Should the therapist observe the patient while the robot performs the exercises? A. Definitely B. Maybe C. Not necessary D. No opinion (Considered as missing data)

Appendix D: Qualitative Questions for Health Professionals In this Appendix, the selected qualitative questions posed to health professionals are given. The responses to the questions are listed, and the number and percentage of respondents that gave each response are denoted in paranthesis. The reponses for each question are sorted in decreasing order of their frequency. The percentages may vary for the same number of repondents, due to the variability in the number of respondents who replied to the questions.

C14. Are there different exercises for patients under different conditions? A. Yes B. No C20∗ . Should the material on the rings be antibacterial? A. Definitely B. Maybe C. Not necessary D. No opinion (Considered as missing data)

First, the answers to the questions will be presented, and then they will be interpreted. C01. Should the robot fix the wrist, or should it allow for the movement of the wrist? ⋄ Fixed wrist (10, 56%) ⋄ Flexible wrist (5, 33%) ⋄ Partially flexible wrist (2, 11%)

Appendix C: Qualitative Questions for Engineers In this Appendix, the selected qualitative questions posed to engineers are given. The responses to the questions are listed, and the number and percentage of respondents that gave each response are denoted in paranthesis. The reponses for each question are sorted in decreasing order of their frequency. B04.

C03. Should the palm of the hand be positioned vertical or parallel to the platform? ⋄ Vertical (12, 67%) ⋄ Parallel (6, 33%)

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C05. What risks does the robot possess? ⋄ Possible tendon rupture (5, 31%) ⋄ Risk of injury (2, 12%)

There is typically a problem with respect to connecting the last phalanx to the robot. How can this problem be solved? No opinion (11, 65%) Adhering or ring design (1, 6%) 5

Break down of sensors (1, 6%) Can be dangereous in post-op tendon injuries (1, 6%) Difficulty in use (1, 6%) Patient can adjust the flexion/extension degrees (1, 6%) Risk of injury, risk of inactivity (1, 6%) Risk of pain (1, 6%) Uncontrollable resistance (1, 6%) Velocity of robot, tendon injury (1, 6%) No risk (1, 6%)

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C06. How can the safety of the robot be maximized? ⋄ Adjustability (5, 29%) ⋄ A button for patient to stop robot (1, 6%) ⋄ A control mechanism for patient (1, 6%) ⋄ A lock for degree adjustments (1, 6%) ⋄ Adjustable speed and resistance (1, 6%) ⋄ Development of robot by the help of experiments (1, 6%) ⋄ Doctor counseling (1, 6%) ⋄ Exercises should be made slowly and carefully (1, 6%) ⋄ Force, speed, and time degress should be adjusted well (1, 6%) ⋄ Non allergic, non smelling, and washable material should be used (1, 6%) ⋄ Quality of sensors should be maximal (1, 6%) ⋄ Speed and resistance adjustability (1, 6%) ⋄ Suitability of robot with finger and adjustable resistance modes (1, 6%)

⋄ ⋄ ⋄ ⋄ ⋄ ⋄ ⋄ ⋄ ⋄

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10-15 times every hour (1, 6%) 10-15 times per hour, 5 min for every finger (1, 6%) 10 times everyday (1, 6%) 15-30 times every day (1, 6%) 15 times for 45 min (1, 6%) 2-3 days per week for 45- 60 mins (1, 6%) 3-4 days per week (1, 6%) 5 min per hour (1, 6%) Everyday after surgery, then decrease the number of exercises (1, 6%) Everyday after surgery, upon the discretion of the threrapist (1, 6%) Everyday in first week, couple of days in the following weeks (1, 6%) Everyday, up to 12th weeks after surgery. 20 times per day (1, 6%) Minimum for 2 weeks, 5 times in a week (1, 6%) Once every 6 hours for 45 min (1, 6%) This changes depending on the situation (1, 6%)

C11. What requires special attention regarding the patient’s health during therapy? ⋄ Consciousness of patient should be preserved (2, 12%) ⋄ Hygiene, (2, 12%) ⋄ Avoid extended forcing (1, 6%) ⋄ Avoid extended tension, avoid swelling (1, 6%) ⋄ Force the patient within the bounds of his/her capability (1, 6%) ⋄ Hygiene, tolorance of patient (1, 6%) ⋄ Hygiene, not overworking the muscles (1, 6%) ⋄ Hygiene, not to injure tendon (1, 6%) ⋄ Not to injure tendon (1, 6%) ⋄ Prevent edama, injuries (1, 6%) ⋄ Threshold of pain (1, 6%) ⋄ Threshold of pain, blood pressure, suitable position (1, 6%) ⋄ Requirements of patients (1, 6%) ⋄ Increase degree of movement every week (1, 6%)

C07. Which actions should be taken in case of a problem during the operation of the robot? ⋄ Therapist should intervene (4, 31%) ⋄ Robot should stop working (3, 23%) ⋄ A chip can be used (1, 8%) ⋄ A safety button for patient (1, 8%) ⋄ Finger should be fixed, doctor should assist (1, 8%) ⋄ Immobile hand and fingers (1, 8%) ⋄ Patient should control the velocity of robot with a button (1, 8%) ⋄ Robot should stop therapy, and patient can demount robot (1, 8%)

C12. Which parameters are considered during therapy exercises (from a given list)? ⋄ Degree of pain, risk factor of injury (5, 26%) ⋄ All of the listed (5, 26%) ⋄ All of the listed, plus psychologic factors (1, 5%) ⋄ All of the listed, plus surgery time, surgery type and injury type (1, 5%) ⋄ Degree of pain, resistance of patient (1, 5%) ⋄ Pain, risk factor of injury (1, 5%) ⋄ Pain, tiredness, risk factor of injury (1, 5%) ⋄ Power of patient, tiredness (1, 5%) ⋄ Risk factor of injury (1, 5%) ⋄ Tiredness (1, 5%)

C09. Is there a standard program applied to patients during therapy? ⋄ No, therapy is different for every patient (8, 57%) ⋄ Passive, active, and assistive movements respectively (3, 21%) ⋄ Grasping exercises (1, 7%) ⋄ Kleirnet (1, 7%) ⋄ Yes, there is standard therapy (1, 7%) C10. What should be the intensity and frequency of the therapy? Please indicate an approximate time interval. ⋄ Everyday (3, 17%) 6

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C13. Should there be extension and flexion movements within the therapy exercises? ⋄ Yes (12, 75%) ⋄ Yes, after 6 weeks (1, 6%) ⋄ Yes, after tendon is healed (1, 6%) ⋄ No (1, 6%) ⋄ Not for every patient (1, 6%)

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Heater/coolant can be added (1, 7%) Movement of single joint, therapy when wrist is movable or immovable (1, 7%) Passive, active, and active-assistive movements (1, 7%) Resistance exercises,grasping exercises (1, 7%) Stretching exercises helps to prevent arthritis (1, 7%)

C18a. There are three main types of exercises that a rehabilitation robot can help: 1) Active-assistive 2) Active 3) Passive. Which type of exercise is suitable to which type of patient? ⋄ Passive, active-assistive, active, active-resistive respectively (5, 42%) ⋄ Every patient needs different kind of therapy (2, 17%) ⋄ All three modes of exercise can be applied every patient (1, 8%) ⋄ Assistive, active-assistive, active-resistive (1, 8%) ⋄ Changes according to patient’s pathologic situation (1, 8%) ⋄ If there is tendon rupture assistive exercises are suitable (1, 8%) ⋄ Robot active up to the 8th week patient, resistive exercises after 12th week (1, 8%)

C15. Are there exercises that a robot can aply more effectively than a therapist would? ⋄ No, a therapist should assist (5, 31%) ⋄ No, every patient needs different therapy style (2, 12%) ⋄ No, therapist decides type of exercises according to patient’s pathologic situation (2, 12%) ⋄ No, a robot can take the place of therapist’s hands (1, 6%) ⋄ No, robot helps therapists (1, 6%) ⋄ No, to feel a therapist with you is important (1, 6%) ⋄ No, therapist should control the resistance (1, 6%) ⋄ Yes, if the dose and speed of exercises can be adjusted well (1, 6%) ⋄ Yes, therapist can take care of the patient for a while, but robot can do it continously (1, 6%) ⋄ Yes, time saving (1, 6%)

C18b. What should be the frequency of therapy exercises? ⋄ Therapist decides (3, 30%) ⋄ 3-4 days in a week (1, 10%) ⋄ 3 times per day (1, 10%) ⋄ 4 times a day for 45 min (1, 10%) ⋄ Everyday (1, 10%) ⋄ Everyday (1, 10%) ⋄ Everyday 1-2 times max 30 min (1, 10%) ⋄ Everyday in a week min 1 hour (1, 10%)

C16. What movements can the robot perform that can contribute to the healing process? ⋄ Active-assistive, active-resistive, passive (2, 13%) ⋄ Gain time, energy (2, 13%) ⋄ Flexion, extension (2, 13%) ⋄ Automatic exercises (1, 7%) ⋄ Decrease edema (1, 7%) ⋄ Fixed range and speed of robot are advantage (1, 7%) ⋄ Gain time (1, 7%) ⋄ Isolated tendon moving exercises (1, 7%) ⋄ It should be considered after a series of experiments on different patients (1, 7%) ⋄ ROM flexion exercises, contracture prevention exercises, muscle strengthen exercises (1, 7%) ⋄ Speeding up the healing process (1, 7%) ⋄ Speeding up the healing process, recovery of the losses (1, 7%)

If there is a prioritization, what should be the order of exercise modes? Assistive, active assistive, resistive (1, 12%) Changes according to patient’s pathologic situation (1, 12%) First 3 months passive, 3-6 months active, 6-9 months resistive (1, 12%) Hot compress should be applied (1, 12%) Passive, active-assistive, active (1, 12%) Passive, active-assistive, active respectively (1, 12%) Passive, active-assistive, active, active-resistive respectively (1, 12%) Passive, active-assistive,active,active-resistive respectively (1, 12%)

C18c. ⋄ ⋄ ⋄ ⋄ ⋄ ⋄ ⋄

C17. Besides flexion and extension, which movements could the robot assist? ⋄ Strengtening exercises (2, 14%) ⋄ None (2, 14%) ⋄ A software program is needed to decide on this (1, 7%) ⋄ Assistive, active-assistive, active-resistive (1, 7%) ⋄ Electrical stimulation and gonionmeter can be added to system (1, 7%) ⋄ Exercise every joint of finger one by one (1, 7%) ⋄ Flexion and extension exercises (1, 7%)

C19. How can the problem of sweating of the hand (during robot movement) be solved? ⋄ Antiperspirant chemical (4, 27%) ⋄ Coolant (2, 14%) ⋄ A special kind of glove (2, 13%) ⋄ Antiperspirant textile (1, 7%) 7

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Antiperspirant textile or chemical (1, 7%) Coolant, medication, hormones (1, 7%) Exercise periodically (1, 7%) Glove (1, 7%) Other, hygiene (1, 7%) Not a problem (1, 7%)

“No”. The three respondents that answered “Yes” indicated that a robot can work more efficiently than a therapist. One of them conditioned this to the careful customization of the dose and speed of the exercises, which requires planning by the therapist. C16 asks which exercises the robot should assist with. There is a general consensus that extension and flexion exercises, which the robot currently supports, are indeed appropriate. Speeding up the healing is also mentioned, by five of the respondents.

C01 asks about the fixation of the wrist, and is related to questions B07∗ and B09. The health professionals were asked if the wrist should be fixed or allowed to move. The answers of show the same distribution as the engineers. 10 professionals suggest that the wrist should be fixed, and two suggest that it should move partially. C03 asks about the positioning of the hands with respect to the ground. 12 of respondents suggest that hands should be vertical to the ground, and the remaining suggest that hands should be parallel to the ground. C05 asks about the risk factor of the robot. According to doctors and therapists, the most important risk factor for the robot is the risk of causing tendon rupture. The other risks are listed in the supplement [16]. C06 asks how to the safety of the robot can be maximized. Adjustability is listed as the most important factor in increasing safety. C07 asks about the precautions that can be taken when there is a problem. General opinion is that the robot should stop working and the therapist should be able to intervene in case of a problem. These were suggested by seven of the 12 professionals answering this question. C09 asks whether there is a standardized program for the patients. Half of the participants mention that every patient needs different exercise program and it is wrong to indicate a standardized program. Others name certain exercises, and identify them as standard. C10 asks about the duration of therapy period. Almost every professional suggests a different therapy program, and the answers are listed above. C11 asks about the issues that require special attention during the therapy. Preserving the consciousness of the patient, ensuring hygiene, and respecting pain thresholds constitute the majority of the answers. C12 asks about the parameters to be considered during exercises, and the one fourth of the answers suggest all the listed parameters as important. C13 asks if the extension and flexion exercises should be part of the therapy. Definite answer is “Yes”, with two professionals conditioning the exercises on the healing of the tendon. C14 is related to C09, and asks if there are different exercise styles for different kinds of situations. All but one of the respondents suggest customized exercises. C15 queries any exercises that a robot may be performing better than a therapist. All but one of the respondents answered

C17 builds upon C16, asking if there are any exercises other than flexion/extension exercises that can be performed or assisted by the robot. The numerous answers are listed in the supplement [16]. C18 consists of three parts: C18a asks which exercise is suitable for which patient. C18b asks about the ideal frequency of the therapy exercises. C18c asks for a prioritization among the types of exercises. The answers are listed in the supplement [16]. C19 asks for a solution to problem of sweating of the hand inside the robot. Suggestions include antiperspirants, coolants, specially designed gloves, and appropriate textiles.

Appendix E: Correlation Analysis This Appendix presents the results of the correlation analysis. In Figure 11 darker and thinner ellipses denote stronger correlations. Ellipses that are inclined to the right denote positive correlations, and those inclined to the left denote negative correlations. In Figure 12 the correlation values are displayed, and the top 4% of cells with positive correlations and top 2% of the cells with negative correlations are colored with light green and pink, respectively. In Figure 13, as a demonstration, a scatter plot is given for the question pair A03c∗ and A03i∗ , which exhibit a strong positive correlation. In the figure, the number of respondents that give an answer pair are reflected in the sizes of the circles.

Appendix F: Mapping the Respondents In this Appendix, the respondents are mapped based on their distances from each other. The distances are Euclidean distances, and are computed according to the answers that they give to the common questions (A01∗ , A02∗ , A03a∗ , . . . A03i∗ , A04∗ , A05∗ ). The dark colored circles denote the engineers, whereas the lighter circles denote the health professionals. The dispersion of the respondent shows that the two groups do not seem to be separated when all the common questions are considered. However, as shown in the paper, there are statistically significant differences between the groups when questions are considered one at a time. 8


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Patoglu et al asme supplementary