Assistive device to enable grasp in stroke patients

GRADUATION PROJECT Assistive Device to enable grasp in stroke patients Sponsor : Self-Sponsored

Volume : 1/1 STUDENT : NIKITA ARORA PROGRAMME : Bachelor of Design

GUIDE : KRISHNESH MEHTA CO-GUIDE : DR. GITA HANDA, AIIMS

2017 INDUSTRIAL DESIGN FACULTY (PRODUCT DESIGN)

National Institute of Design, Ahmedabad

The Evaluation Jury recommends NIKITA ARORA for the Degree of the National Institute of Design

IN INDUSTRIAL DESIGN (PRODUCT DESIGN)

herewith, for the project titled "ASSISTIVE DEVICE TO ENABLE GRASP IN STROKE PATIENTS" on fulfilling the further requirements by

Chairman Members :

*Subsequent remarks regarding fulfilling the requirements :

Registrar(Academics)

*

COPYRIGHT Š 2017 Student document publication meant for private circulation only.

No part of this document can be reproduced or transmitted in any form or by any means electronically or mechanically, including photo copying, xerography or video recording without permission from the publisherNikita Arora & National Institute of Design.

Typeface Used Lato Edited & Designed By Nikita Arora nikitarora8@gmail.com www.behance.net/nikitaarora08 Processed & Published At National Institute of Design Paldi, Ahmedabad - 380007 Gujarat, India www.nid.edu

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Graduation Project | Design of an upper limb assistive device for stroke patients

Originality Statement I hereby declare that this submission is my own work and it contains no full or substantial copy of previously published material, or it does not even contain substantial proportions of material which have been accepted for the award of any other degree or final graduation of any other educational institution, except where due acknowledgement is made in this graduation project. Moreover I also declare that none of the concepts are borrowed or copied without due acknowledgement. I further declare that the intellectual content of this graduation project is the product of my own work, except to the extent that assistance from others in the project’s design and conception or in style, presentation and linguistic expression is acknowledged. This graduation project (or part of it) was not and will not be submited as assessed work in any other academic course.

Student Name in Full:

Nikita Arora

Signature: Date:

Copyright Statement I hereby grant the National Institute of Design the right to archive and to make available my graduation project/thesis/dissertation in whole or in part in the Institute’s Knowledge Management Centre in all forms of media, now or hereafter known, subject to the provisions of the Copyright Act. I have either used no substantial portions of copyright material in my document or I have obtained permission to use copyright material.

Student Name in Full: Nikita Arora Signature: Date:

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Graduation Project | Design of an upper limb assistive device for stroke patients

To mum and dadd, thank you for everything.

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Graduation Project | Design of an upper limb assistive device for stroke patients

Sawan An assistive device for stroke patients to make them independent

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Graduation Project | Design of an upper limb assistive device for stroke patients

Imagine no possessions I wonder if you can No need for greed or hunger A brotherhood of man Imagine all the people sharing all the world, You may say I’m a dreamer But I’m not the only one I hope some day you’ll join us And the world will be as one John Lennon

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Graduation Project | Design of an upper limb assistive device for stroke patients

Preface The Graduation Project is the final academic project for the student, marking an end to the student’s academic tenure at the National Institute of Design. It is marked by the culmination of a substancial investigation in the field of design on a topic closely allied to their discipline of study. It is through the graduation project and subsequent documentation of the same that this investigation takes place.

I started this year with researching on one of the most upcoming topics, last mile mobility. I had extensive talks with many experts in the field, participated in a workshop and collected data of metro travel on different lines. By the end of two months I decided to drop this project as I realised it isn’t a project to be done by one individual. It requires systemic changes and it I alone could not do justice to it.

Everyone finds their own definition of design. For me, my journey in the last one year has been a defining factor in the development of my understanding of design. A chance to design a product with two great batchmates and get funding for the same to my journey to Glasgow School of Art, Scotland where I was an Indian student in a class with only 3 Scottish students of 28; Greek, Swedish, Latvian, Italian, French, Japanese, Finnish and German being few of the rest. I believe design is a profession deeply rooted in culture and so it also gave me an insight into their design practices.

This was the time when I visited Amar Jyoti Charitable trust in Delhi where I gave myself two weeks to do need identification. By the end of two weeks and with help from my college seniors Pranay & Manisha I managed to narrow down on one. I was intrigued upon seeing a boy have problems in holding objects, on enquiring I was told that he had had a stroke.

This documents my journey from that moment forward.

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Dr. Krishnesh Mehta Professor National Institute of Design

Dr. Gita Handa Professor AIIMS

Praveen Nahar Professor National Institute of Design

Feroz Khan Workshop Technician AIIMS

Sawan Clerk Wipro

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Graduation Project | Design of an upper limb assistive device for stroke patients

Acknowledgements This project is the result of the collective efforts of various people and I’m grateful to each on of them for their support. I am grateful to my parents who constantly encouraged me to take up a project of my liking and NID for giving me freedom to do so.

My special thanks to Krishnesh Mehta and Dr. Gita Handa for their unrelenting support. I would also like to thank Praveen Nahar, who has inspired, critiqued, challenged and encouraged me to find my own definition of design, throughout my time at NID. I would like to thank Mr. Feroz for working with me during the prototyping stage and for coming to my rescue each time an idea failed and help set it working.

I would specially like to thank my father, without his knowledge of materials, manufacturing processes and electronics I couldn’t have come this far in the development of this product. My mother, for nurturing my interest in the field of medicine. I was always inspired and intrigued by her profession and I believe this project was the closest I could have been to working with doctors.

I am grateful to the people at the AIIMS prosthetics workshop for helping me resolve any problems relating to the prototype.

Of course, I would forever be indebted to Sawan and his family for having faith in my work and helping me during the sometimes bothersome process of development.

A big thanks to Mr. Rajesh for teaching me how to approach stroke patients and do their assessment. Mr. Sachin and Dr. Rashmikanth Shah for offering their expertise at a crucial time. Dr. Jyoti Gupta for having faith in my project and allowing me to interact with multiple patients, this formed the basis of my project.

I would specially like to thank Satya Prakash and his team from Limbot technologies for giving me valuable feedback on the technical aspects of the project. Also, Sandeep Shukla for helping me in the development of a section of the prototype.

Pranay for his craziness and much needed support, Sonam for his wise words and to Product Design batch 2013 for sailing in the same boat and sharing each other’s experiences.

Misha and Aditi for hosting me during the Ahmedabad visits, their warm presence kept me going.

Lastly, I would like to thank Mum, Dadd, Ashima,Kiran and Sandeep Dongre for being my support system.

Manisha Laroia, without whom I would have been absolutely lost! Thank you for introducing me to AIIMS and for the lengthy discussions about my document.

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Contents I Background

III Biomechanics of the human hand.

A. Preface B. Acknowledgements C. About National Institute of Design D. What is Product Design?

E. Synopsis F. About Amar Jyoti G. About Ram Manohar Lohia (RML) Hospital H. About All India Institute of Medical Sciences (AIIMS)

A. Understanding Human Hand B. Patient Assessment Resting Position of Normal hand Resting Position of Spastic hand C. Empathetic Study Inferences

II Understanding stroke.

A. History of stroke B. The Story of stroke Patient Care Pathway Brunnstrom stages of recovery C. Stroke Disorder D. Stroke Scenario E. Neuromuscular System

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Graduation Project | Design of an upper limb assistive device for stroke patients

Problem statement

IV Understanding the market.

A. B. C. D. E. F. G. H. I.

Desk Research Saebo Flex Bioness H200 Exo Glove Poly Mock-up A.V1 Visit to PMR Dept., RML Hospital, Delhi Visit to Chandni Chowk, Delhi Visit to Healthy Future, Ahmedabad National Design Incubation Centre, Ahmedabad

Conclusion

Inferences

Revised Brief

1. Learnings 2. Way Forward References Citations

V Concept Generation

Appendix

A Concept B.V1 B. Mock-up C.V1 C. Some failed attempts D. Task Flow with Sawan E. Prototype 1.V1 F. Experiments with mechanisms G. Motor movements H. Improvements I. Prototype 1.V2 J. Sequence of hand movements with Sawan K. Sawan

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Graduation Project | Design of an upper limb assistive device for stroke patients

About NID On April 7, 1958, the Eameses presented the India Report to the Government of India. The Eames Report defined the underlying spirit that would lead to the founding of NID and beginning of design education in India. Based on the recommendations made in the India Report, the Government of India with the assistance of the Ford Foundation and the Sarabhai family established the National Institute of Industrial Design, as it was originally called as an autonomous all-India body in September 1961 at Ahmedabad.

The National Institute of Design (NID) is internationally acclaimed as one of the foremost multi-disciplinary institutions in the field of design education and research. The institution functions as an autonomous body under the department of Industrial Policy & Promotion, Ministruy of Commerce and Industry, Government of India. NID has been declared Ínstitute fo National Importance’by the Act of Parliament, by virtue of the National Institute of Design Act 2014.

NID is recognised by the Dept. of Scientific & Industrial Research (DSIR) under Ministry of Science and Technology, Government of India, as a scientific and industrial design research organisation. NID has been a pioneer in industrial design education after Bahaus and Ulm in Germany and is known for its persuit of design excellence to make Designed in India, Made for the worl, a reality. NID’s graduates have made a mark in key sectors of commerce, industry and social development by taking on the role of a catalyst in thought and leadership.

It offers 8 undergraduate design courses and 19 graduate design courses, spread over four campuses in four cities; namely Ahmedabad, Gandhinagar, Bengaluru and Vijayawadh.

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Saebo Flex by Saebo Source: saebo.com /saebostretch

Car Design Concept cardesignnews.com/articles/new prospects

MUJI Statonery by Naoto Fukasawa and Kenya Hara MUJI Statonery by Naoto Fukasawa and Kenya Hara Eames Chair by Herman Miller Source: https://www.yliving.com/herman-miller-eames-lounge-

MOYO Fetal heart-rate monitor by LAERDAL Source: www.laerdalglobalhealth.com

Cardboard Incubator by Malav Sanghvi Source: http://ahmedabadmirror.indiatimes.com/ ahmedabad/education//articleshow/49693389.cms?i Hippo Roll by Pettie Petzer and Johan Jonker Source: Wellowwater.org

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Graduation Project | Design of an upper limb assistive device for stroke patients

Lifestraw by Vestergaard Source: www.wellowater.org`

What is Product Design?

Product Design is concerned primarily with the relationship between products, systems and those who use them. The Product Design programme at NID inculcates user-centric approach and processes. Responsibility and concern towards the social, physical and ecological environments is emphasised in the process of developing innovative ideas.

Design projects form the core of a product designer’s education, with gradual increase in level of complexity and cover broad areas that product designers are likely to encounter in their professional careers. Students are actively encouraged to participate in collaborative projects with industrial houses, social sectors, government and MNCs.

The Product Design programme assimilates inputs in diverse domains such as human factors, cognitive ergonomics, form studies, studio skills, advance CAD (Computer Aided Design), research methods, design management, materials & manufacturing processes & social sciences. Emphasis is on process centric approach which shapes a student’s education through participation and teamwork.

Design projects can be broadly classified into domains of: Design for Industry Design for quality of life Design for healthcare Design for social impact Design for sustainability Design led futures

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Graduation Project | Design of an upper limb assistive device for stroke patients

Synopsis This project is my journey in exploring all the fields related to design; such as medicine, mechanical engineering and electronics.

It started out with a patient named Sawan, he had had a stroke one year back and was undergoing rehabilitation for the same, whe we met. After seeing him struggle with his hand I decided that there was something I wanted to do about it. I didn’t know what it was at the time.

After research I built connections in order to start prototyping.

I started by recreating what is made in the prosthetics workshop and then using the skeleton to then build further along with modifications in usability, comfort and functionality.

After undergoing the whole process I realised that I had unknowingly followed the Biodesign Process so commonly talked about. ie. I identified, invented and then hopefully will get to implement soon as well.

I started by doing some research with the help of my mother, who is an anaesthetist and helped me connect to a lot of the therapists or neurologists that I came across in that duration. After the problem area had been identified I tried to understand the viability of working in this space and why not enough has been done already.

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Source: http://www.amarjyotirehab.org/ 24

Graduation Project | Design of an upper limb assistive device for stroke patients

Delhi

About Amar Jyoti Charitable Trust Amar Jyoti Research and Rehabilitation Centre was established in 1981 at Delhi, under the aegis of Amar Jyoti Charitable Trust. Amar Jyoti is a voluntary organization rendering rehabilitative services to persons with disabilities through a holistic approach of inclusive education, medical care, vocational training, child guidance and self-employment.

The Centre has various units including Institute of Physiotherapy, Amar Jyoti School, Teachers, Training Centre for Special Education, Orthotic and Prosthetic Workshop, Vocational Training Centre, Child Guidance Centre and Medical Care Centre.

The Physiotherapy department is well equipped with most modalities like IFT, Laser, Ultrasound, etc. for patient care treats almost 11,000 patients a year. There is also one Occupational Therapy Department that plays a vital role in making each patient independent in fine motor, sensory integrative and pre-vocational skills.

Adaptation, modification and exercise are designed to enhance independent performance of self-help skills. Follow-up is maintained through regular patient - therapist meetings and a customized home programme. [0.1]

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Source: http://rmlh.nic.in/ 26

Graduation Project | Design of an upper limb assistive device for stroke patients

Delhi

About RML Hospital Dr. Ram Manohar Lohia (RML) Hospital, formerly known as Willingdon Hospital, was established by the British for their staff and had only 54 beds. After independence, its control was shifted to New Delhi Municipal Committee.

In 1954, its control was again transferred to the Central Government of Independent India. It is fully funded by the Government of India (Ministry of Health Family Welfare). No Emergency Patients are Refused treatment in this Hospital.

Physical medicine and rehabilitation speciality provides for the management of disorders that alter the function and performance of the patient. Emphasis is placed on the optimization of function. In restorative rehabilitation, the goal is to restore a function that you have lost. Examples include short-term rehabilitation that usually follows a stroke or a hip fracture. In maintenance rehabilitation, the goal is to maintain and strengthen a function. Maintenance rehabilitation is less intense, with physical therapy or occupational therapy continued three times a week as an outpatient. With longerterm therapy, possibly more function can be gained or more functional loss can be prevented. [0.2]

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Graduation Project | Design of an upper limb assistive device for stroke patients

Delhi

About AIIMS Hospital A generous grant from New Zealand under the Colombo Plan made it possible to lay the foundation stone of All India Institute of Medical Sciences (AIIMS) in 1952.The AIIMS was finally created in 1956,as an autonomous institution through an Act of Parliament ,to serve as a nucleus for nurturing excellence in all aspect of health care.

The Institute has comprehensive facilities for teaching, research and patient-care. As provided in the Act, AIIMS conducts teaching programs in medical and para-medical courses both at undergraduate and postgraduate levels and awards its own degrees. Teaching and research are conducted in 42 disciplines. In the field of medical research AIIMS is the lead, having more than 600 research publications by its faculty and researchers in a year.

The PMR Specialist doctor is called “Physiatrist� who treats the patient as a whole with the goal to help patients understand their condition and provide the tools and resources to manage a successful healing process with the ultimate aim at improving the functioning of the patient. The continuity of care offers a variety of treatment methods to reduce or eliminate challenges and address recurrence. The services offered are related to musculoskeletal problems, brain injury, stroke, spinal cord injury, acute and chronic pain management, amputation, work injuries, orthopedic injuries, sports medicine, pediatric neuromusculo-skeletal problems and the developmental delays. [0.3]

The Department of Physical Medicine and Rehabilitation is actively engaged in providing high quality clinical care, education and research in the field of Physical Medicine and Rehabilitation and is dedicated to improving quality of life of persons with physically disabling conditions.

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Source: http://as.wiley.com/WileyCDA/WileyTitle/productCd-1118442342.html 30

Graduation Project | Design of an upper limb assistive device for stroke patients

Understanding Stroke.

The medical disorder and its presentation

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Graduation Project | Design of an upper limb assistive device for stroke patients

What is stroke?

Stroke is a ‘brain-attack’. It occurs when blood flow to an area of the brain is cut off. When this happens, brain cells are deprived of oxygen and begin to die. Brain cells are like memory pockets that store the memory of actions and experiences, when they start dying different abilities controlled by those pockets such as memory and muscle control are lost.

Awareness in the medical community is lacking in order for better management of stroke cases. Care should be provided to the patient immediately after the attack or within 6 hours, at the most.

Is it evident that there is a need to create more efficient infrastructure; however it is also understood that such systemic changes take a long time to develop, taking into account the complex structure of medical aid in the country.

How a person is affected by their stroke depends on where the stroke occurs, in the brain and how much of it is affected. Generally more than 2/3rds of survivors would have some type of disability. [1]

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A. History of stroke How stroke-care has evolved over the years

Image 1A.1On February 21, 1848, just after participating in a vote on the floor of the House of Representatives, Quincy Adams succumbed to a massive stroke Source: http://www.history.com/topics/us-presidents/john-quincy-adams/pictures/john-quincy-adams/death-of-john-quincy-adams 34

Graduation Project | Design of an upper limb assistive device for stroke patients

Hippocrates, the father of medicine, first recognized stroke over 2,400 years ago. At this time stroke was called apoplexy, which means “struck down by violence” in Greek. This was due to the fact that a person developed sudden paralysis and change in well-being. Doctors had little knowledge of the anatomy and function of the brain, the cause of stroke, or how to treat it.

It was not until the mid-1600s that Jacob Wepfer found that patients who died with apoplexy had bleeding in the brain.

He also discovered that a blockage in one of the brain’s blood vessels could cause apoplexy.

Medical science continued to study the cause, symptoms, and treatment of apoplexy and, finally, in 1928, apoplexy was divided into categories based on the cause of the blood vessel problem. This led to the terms stroke or “cerebral vascular accident (CVA).”

The term brain attack also conveys a more urgent call for immediate action and emergency treatment by the general public.

Stroke is now often referred to as a “brain attack” to denote the fact that it is caused by a lack of blood supply to the brain, very much like a heart attack is caused by a lack of blood supply to the heart.

One of the earliest known stroke treatments occurred in the 1800s, when surgeons began performing surgery on the carotid arteries. These are the arteries that supply much of the blood flow to the brain. Clots that develop in the carotid arteries are often responsible for causing a stroke. Surgeons began operating on the carotid arteries to reduce cholesterol buildup and remove blockages that could then lead to a stroke.

The first documented carotid artery surgery in the United States was in 1807. Dr. Amos Twitchell performed the surgery in New Hampshire. Today, the procedure is known as a carotid endarterectomy.

Today, there is a wealth of information available on the cause, prevention, risk, and treatment of stroke. [2]

Most stroke victims now have a good chance for survival and recovery with Immediate treatment, supportive care, and rehabilitation.

While carotid artery surgeries certainly helped to prevent stroke, there were few treatments available to actually treat a stroke and reduce its effects. Most treatments were more focused on helping people manage any difficulties after a stroke, such as speech impairments, eating problems, or lasting weakness on one side of the body. It wasn’t until 1996 that a more effective treatment was implemented. During that year, the United States Food & Drug Administration (FDA) approved the use of tissue plasminogen activator (TPA), a medication that breaks up the blood clots that cause ischemic strokes.

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B. Story of Stroke Journey of a patient through the stages of recovery After a bit of reading on stroke I went to meet Mrs Sampada to know how to further develop my understanding of the condition. From her I understood that this is a really common condition across the globe, more so in the poorer countries.

Risk factors leading to increased probability of stroke are high cholesterol, smoking, excessive drinking and obesity, among others.

Stroke is also known as a Cerebro Vascular Accident (CVA), it usually affects one side of the body. Movement and sensation of one side of the body is controlled by the opposite side of the brain. This means that if your stroke affected the left side of your brain, you will have problems with the right side of your body. This is called hemi(half)-paresis (muscular weakness) or unilateral paresis. [3]

This illustrates the patient Care Pathway (Patient Care Pathway), This refers to the pathway followed by a patient through the course of the stroke and the rehabilitation following it. It also relates to the people he comes across during this period.

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Graduation Project | Design of an upper limb assistive device for stroke patients

The Story of

Stroke

Witness/ passerbyPatientStroke. The Story ofThis illustrates the ideal journey/Patient Care Pathway (PCP) of a patient who had a moderately severe stroke, from the moment of the attack, through the rehabilitation stage and full recovery. Keeping in mind that this is the ideal sequence of events.

Rahul works at an IT firm, his job requires him to do extensive work on the PC and involves a lot of typing as well. He’s in his mid-twenties, is the only child and he stays with his parents.

One day as he’s working on his desk, he has a stroke.

SurgeonCaretakerTherapist.

Patient Witness/ passerby Surgeon Caretaker Therapist

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Graduation Project | Design of an upper limb assistive device for stroke patients

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The Brunnstrom stages and recovery patterns: The Brunnstrom Approach was developed in the 1960’s by Signe Brunnstrom, an occupational and physical therapist from Sweden. With seven stages, the Brunnstrom Approach breaks down how motor control can be restored throughout the body after suffering a stroke. [4]

Even though this project caters to patients in the 2nd-5th stage it is important to understand the 1st stage before moving onto the 2nd one.

Therapy should start from the next day of the stroke itself, this increases the patient’s chances of full recovery.

Along with understanding the different stages of recovery it was also important for me to understand the devices that are advised by the therapist and used by the patient during these stages, in order to develop a comprehensive need statement.

Image IB.1: Mrs Signe Brunnstrom Source: http://el-fisioterapeuta.blogspot.in/2015/07/introduccion-que-es-elmetodo-brunnstrom.html

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Graduation Project | Design of an upper limb assistive device for stroke patients

Stage #1: Flaccidity Though stroke does serious neurological damage, other healthy brain cells and muscles can help make up for some of this damage. In fact, the patient’s own body is full of tools that reduce complications and increase their likelihood of entering new stages of recovery. It’s never too early to start retraining the body and brain after stroke, even if patients are still experiencing flaccid paralysis and hypotonia.

The first stage in Brunnstrom’s approach is the initial period of shock immediately after stroke, when the patient is coming to terms with the nature of the disorder and the family also has time to adjust to it. This is the time when flaccid paralysis sets in. This paralysis is caused by nerve damage that disrupts the communication between the nerves and muscles, leading to a lack of movement of those muscles.

In the initial stage, the patient cannot initiate any movement on the affected side of the body. If the patient continues in this state without therapy, the unused muscle would become weaker and weaker and begin to atrophy (go waste). To conclude, muscles need to be used in order to retain their tone and flaccid paralysis prevents them from using it.

As mentioned earlier, tone refers to the resistance of the muscle to passive stretch during resting state. The medical term for this loss of muscle tone is hyptonia. Hyptonia causes weakness and sometimes numbness that seriously interferes with a patient’s quality of life. In addition to therapy exercises and treatments that reduce the severity of hypotonia, this Stage 1 condition also requires lifestyle modifications to protect the affected limbs from injury. [5]

Image IB.2: Muscle atrophy Source: http://reidhosp.adam.com/content. aspx?productId=39&pid=1&gid=003188

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Advised for flaccidity: C-Bar Splint During the period of flaccidity the patient is advised to wear the functional hand splint. This position is maintained because it provides the best balance of resting length and force production so the hand can function when the patient mobilizes it again.

The patient is advised to wear this at night before going to sleep and for few hours during the day. This ensures that the muscles don’t atrophy by maintaining the hand in this position in the absence of synergic movement (muscles come to their relaxed state while the patient sleeps and spasticity reduces).

Usually if a hospital has a physiotherapy centre it is likely that it also has a prosthetics and orthotics workshop. If this is the case the patient is advised to get a customised splint made from that workshop. Patients are rarely regular in wearing it and some don’t even get access to such a facility. The functional hand position would be explained further in the next section.

Image IB.3: C-Bar splint/Funtional hand splint Source: http://www.mediroyal.se/en/product/preformed-functional-splint

Later I found out that Sawan also owned a similar splint which he had gotten made at the physiotherapy centre at Amar Jyoti.

Image IB.4: Flat mitten splint Source: https://www.ncmedical.com/item_1094.html 42

Graduation Project | Design of an upper limb assistive device for stroke patients

Stage #2: Spasticity appears Muscles begin to make small, spastic, and abnormal movements during this stage. While these movements are mostly involuntary, they can be a promising sign during your recovery. There is generally an absence of voluntary movements in stage two.

Unused limbs still need stimulation to maintain or form connections to neurons. Though the nerves and connections that originally controlled your affected limbs may be damaged too much to create voluntary movements, it could still be possible to regain movement in later stages of recovery.

In order to leave this possibility open and prevent the body’s tendency toward learned non-use, it’s important to continue using and moving your affected limbs and muscles as much as possible.

Muscle synergies result from muscles coordinating movements to perform different tasks. These muscle synergies allow common patterns of movement that involve either cooperative or reciprocal activation of muscle. Because the muscles are linked, one activated muscle may lead to partial or complete responses in other muscles.

These synergies may limit patient’s muscles to certain movements, preventing them from completing the voluntary movements they want to make. However, as neurological development and cell regrowth occurs after a stroke, some new connections may be formed to impaired muscle tissue. [6] There are 2 types of synergic movements that can be seen; the flexor synergy, includes the external rotation of the shoulder, flexion of the elbow, and supination of the forearm. The second, the extensor synergy, includes internal rotation of the shoulder with elbow extension and pronation of the forearm.

All the stroke patients I interacted with during the course of the project presented flexor synergies.

Image IB.3: Flexor synergy Source: https://www.cambridge.org/core/books/textbook-of-neuralrepair-and-rehabilitation/evidence-based-benefit-of-rehabilitation-afterstroke/E921EE9BA387BAF68BFD12DBD8CE1CC6

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Stage #3: Spasticity increases Spasticity in muscles increase during stage three of stroke recovery, reaching its peak. Spasticity is a feeling of unusually stiff, tight, or pulled muscles. It is caused by damage from a stroke to nerve pathways within the brain or spinal cord that control muscle movement. The lack of ability to restrict the brain’s motor neurons causes muscles to contract too often.

During stage 3, synergy patterns also start to emerge and minimal voluntary movements should be expected. This increase refers to the improved ability to initiate a movement but not control it (yet). The appearance of synergy patterns and coordination between muscles facilitate the voluntary movements which become stronger with occupational and physical therapy in the later stages.

Muscles with severe spasticity, like the ones in stage 3 of stroke recovery, are likely to be more limited in their ability to exercise and may require help to do this. Patients and family/ caregivers should be educated about the importance of maintaining range of motion and doing daily exercises. It is important to minimize highly stressful activities this early in training.

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Image IB.5: Physiotherapy post stroke Source: http://positivemed.com/2017/05/16/physiotherapy-stroke/

Graduation Project | Design of an upper limb assistive device for stroke patients

Stage #4: Spasticity reduces During stage four of stroke recovery, spastic muscle movement start to decline. Patients will regain control mostly in the extremities, and they will have a limited ability to move normally. The movements may still be out of sync with muscle synergies, but this will improve over the length of this stage.

The focus during this stage is to strengthen and improve muscle control. Now that you are regaining motor control and can start to make normal, controlled movements on a limited basis, you can start to build strength back in your limbs and continue work on your range of motion. Continuing to stretch out your muscles is still important in this stage.

Patient can begin active range-of-motion (AROM) exercises once he has regained some muscle control and can perform some exercises without assistance. They often involve moving a limb along its full range of motion, like bending an elbow or rotating a wrist. AROM exercises increase flexibility, muscle strength, and endurance.

Image IB.6: Stroke patients take time to come to terms with the reson for their condition.

They seek help from wherever they can.

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Stage #5: Voluntary movement are possible During this stage spasticity continues to decline and synergy patterns become more co-ordinated. Abnormal movements also start to decline.

Voluntary movements are purposeful and goal directed.

They are learned movements that improve with repetition or practice and require less attention. Some examples include combing hair, swinging a bat, driving a car, swimming, and using eating utensils.

During this stage the patient starts to improve in grip strengthening and co-ordination exercises. One such equipment is shown in Image 1B.7 where the patient is practicing on the peg & board in which there are pegs of different cross-sections which the patient is required to pick up the peg and place it in the respective negative space.

Image IB.7: Peg and board grip strengthening exercise

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Graduation Project | Design of an upper limb assistive device for stroke patients

Stage #6: Spasticity dissapears

Stage #7: Full recovery

At stage six, spasticity in muscle movement disappears completely. You are able to move individual joints, and synergy patterns become much more coordinated.

The last stage in Brunnstrom’s Approach is when you regain full function in the areas affected by the stroke. You are now able to move your arms, legs, hands, and feet in a controlled and voluntary manner.

Motor control is almost fully restored, and you can coordinate complex reaching movements in the affected extremities.

Abnormal or spastic movements have ceased, and a full recovery may be on the horizon.

Although because of the lack of good healthcare services at the beginning of the PCP (as mentioned in the fold out), stroke patients seldom reach this stage.

Since you have full control over your muscle movements, synergy patterns have also returned to normal.

Reaching stage seven is the ultimate goal for therapists and patients alike but with the condition of stroke care in India, highly unlikely in the near future.

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C. Stroke disorder How and why stroke happens After a bit of reading on stroke I went to meet Mrs Sampada to know how to further develop my understanding of the condition. From her I understood that this is a really common condition across the globe, more so in the poorer countries.

This difference axists not only because of the lack of access to healthcare but also because of the cultural differences.

Risk factors leading to increased probability of stroke are high cholesterol, smoking, excessive drinking and obesity, among others.

A stroke can occur at any time. It takes place due to the lack of blood flow to a portion of the brain There can be three types of strokes that may occur, ischemic, hemorrhagic or TIA (Transient Ischemic Attack): Hemorrhagic Stroke: The burstng of a brain aneurysm, trauma, blood thinning medications or hypertension lead to such a stroke. Though less common, this type of stroke mostly results in death.

Stroke is also known as a Cerebro Vascular Accident (CVA), it usually affects one side of the body. Movement and sensation of one side of the body is controlled by the opposite side of the brain. This means that if your stroke affected the left side of your brain, you will have problems with the right side of your body. This is called hemi(half)paresis (muscular weakness) or unilateral paresis. [7]

Image IC.2: What is hemorrhagic Stroke (Source: MAYO Foundation for Medical Education and Research)

Image IC.1: What is hemiplegia

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Graduation Project | Design of an upper limb assistive device for stroke patients

Source: Heart and Stroke Foundation of Canada)

Ischemic Stroke: The most common form, accounting for around 85% of strokes. It caused by blockages or narrowing of arteries that lead to the brain, resulting in schemiaseverely reduced blood flow that damages the brain.

TIA (Transient Ischemic Attack): These can be of different types because the flow of blood to the brain is only briefly interrupted. TIAs are similar to ischemic strokes in that they are often caused due to blood clots or other clots. According to the Centre for Disease Control and Prevention, over a third of people who experince TIA go on to have a major stroke within a year, if not given any treatment. [8]

Recovery after stroke should ideally start from the day after the attack but this rarely happens; usually the patient takes some time to come to terms with the disorder and motivate himself to recover.

Ischemic strokes make up nearly 75% of all strokes.

Image IC.3: What is ischemic Stroke Source: Heart and Stroke Foundation of Canada)

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D. Stroke scenario Prevalence and presentation of the disorder all over the world

(Source: https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/stroke/v/what-is-a-stroke

Image ID.1: Prevelance of stroke in the world 50

Graduation Project | Design of an upper limb assistive device for stroke patients

Aging, unhealthy diets, tobacco use, physical inactivity, all fuel a growing epidemic of high blood pressure, high cholestrol, obesity, diabetes, stroke, heart disease and Vascular Cognitive impairment. Four out of five strokes occur in low and middle income countries, these are people who can least afford to deal with the consequences of stroke.

Worldwide stroke is a leading cause of serious disability. [9]

Changing habits and sedentiary lifestyles have made the incidents of stroke more prevalent among South Asians, notably Indians, it can either induce permanent disability or prove fatal, even as preventive measures are at hand.

Alarmingly, there is higher prevalence of the disorder in the country’s youth because of a lifestyle where smoking is fashionable and alcohol consumption is considered trendy, in addition to an overall increase in stress levels compared to previous generations.

According to a recent study published in the Journal of Stroke by two experts, Jeyaraj Durai Pandian and Paulin Sudhan, the prevalence rate of stroke is 84-262 per 100,000 population in rural India and 334-424 out of 100,000 population in cities.

In India, with a population of 1.3 billion, around 1.7 million stroke cases happen each year.

It is assumed that the average age of patients with strokes in developing countries is usually 15 years younger than those in the developed country. In India, nearly one-fifth of the patients with first ever stroke admitted to hospitals is estimated at 40 years or less.

A study published in October 2013 in a leading health journal The Lancet, titled ‘Global and Regional Burden of Stroke’- which looked at its incidence between 1990-2010 - a third of all strokes globally now occur in the 20-64 year age group. Even as the overall death rate due to stroke was down globally, the number of people who succumed to it was 10 times higher in the lower and middle-income countries, said the study, predicting that the numbers will double worldwide by 2030. [10] From the preventive healthcare point of view, our country needs to be educated; doctors will be of little help in this sphere. The government would have to take initiatives to facilitate awareness among both rural and urban populations. Considering a patient reached the nearest Point of Care, there is still no assurance that he will be treated by a professional well trained in the treatment of stroke. There is a lack of knowledge on stroke and the treatment to be given for it.

After someone suffers a stroke, there aren’t well defined check-points for the patient’s care. There are few reasons why this gap exists; first being that people from lower income groups are more susceptible to stroke and ironically the ones with least access to healthcare. Second reason being that if they reach a hospital in time they are either treated in a hurry or treated by an individual with inadequate knowledge in dealing with stroke patients and because of these gaps most patients often recover much slower than what would have been possible.

After the clot or bleed has been treated, the patients are relieved and advised to go to a physiotherapy centre or a Physical Medicine and Rehabilitation (PMR) Dept. immediately.

This is where their rehabilitation in order to get back to their normal life, begins.

80% of patients first get admitted to nearby small hospitals or clinics that aren’t well equipped to handle such cases.

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E. Neuro-muscular system: What it is and how it functions in case of Stroke patients

The neuromuscular system includes all the muscles in the body and the nerves serving them. Every movement in your body requires communication between the brain and the muscles.

The nervous system provides the link between thoughts and actions by relaying messages to the brain. Our nerves have cells called neurons, neurons carry this message from the brain via the spinal cord. The neurons that carry these messages to the muscles are called motor neurons. Each motor neuron ending sits very close to a muscle fibre. Where they sit together is called a neuromuscular junction.

When we want to perform a task, say close our little finger; our brain generates a signal which allows the motor neuron to release a chemical, which is picked up by the muscle fibre that operates the flexor muscles of the little finger, this tells the muscle fibre to contract, which makes the finger move, all this in a split second! [11]

Hence the smooth functioning of the neuro-muscular system is essential for our daily life to go on smoothly. Any gap in this communication will cause abnormalities in the body movements.

Stroke causes a damage in the neurological system, which results in hemiperesis of one half of the body. The importance of this communication between the two systems in the body is felt only when it goes awry.

Due to such a disruption even though the signals get generated in the brain, they have issues being transmitted to the neurons close to the target muscles of the affected side of the body. This confusion causes irregular transmission of signals, leading to irregularities in the body movements. So the simplest of movements that were happening seamlessly only yesterday can’t happen today.

Even though this condition may seem similar to what is faced by amputees, the difference is seen when we consider the psychosomatic effects of this disorder. In the case of amputees; the patient can physically see the absence of an arm, hence gets accustomed to using the other hand, whereas in case of stroke; the patient takes a long time to understand why the hand which looks just the same, doesn’t work the same way.

Image :Types of neurological disorders causing paralysis or peresis Source: http://www.newhealthadvisor.com/Hemiplegia-vs-Hemiparesis.html

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Graduation Project | Design of an upper limb assistive device for stroke patients

What is neuroplasticity?

Neuroplasticity is a combination of two words, neuron and plasticity. Neurons are the nerve cells in the brain and the word plasticity refers to something with the capability to be remolded or re-organised, hence it refers to the brain’s ability to reorganise itself by making new neural connections at any age. It is also referred to as brain plasticity or malleability.

Neuroplasticity allows the neurons in the brain to compensate for injury and adjust their activities in response to new situations. In case of a brain disorder (in this case, stroke); the brain compensates for damage in effect by reorganising and forming new connections between intact neurons. In order for the formation of such connections, the brain needs to be stimulated. The rehabilitation process may be considered as bringing the stroke patients back to when they were newborns. [12]

Image :How a thought is translated to an action Source: www.backyardbrains.com /experiments/muscleSpikerbox Image :Neuromuscular junction Source: https://www.t-nation.com/training/nervous-muscle

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What is spasticity?

Spasticity is a muscle control disorder that is characterised by tight or stiff muscles and an inability to control them.

It is caused due to an imbalance of signals from the central nervous system to the muscles.

In this condition there is possibility of recovery to the patient’s normal hand movements although it also depends on the severity of the stroke and the frequency with which the patient goes for physiotherapy or exercise.

This may be related to the natural ability of the body to curlup, as seen in case of the posture of the foetus as well.

Not only is this a physical disadvantage but it also affects the patient pyschologically. It is mentally debilatating for the patient to regularly try and fail at doing a basic task, such as opening his fingers.

To further understand the meaning of these terms and also understand the biomechanics of the hand, I went to RML Hospital to examine some stroke patients. [13]

Image :Spastic hand Source: http://rehab-insider.advanceweb.com/the-magiccure-for-spasticity-reduction/

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Graduation Project | Design of an upper limb assistive device for stroke patients

What is contracture?

This refers to the permanent shortening of a muscle, in case of stroke. This happens due to prolonged hypertonia (increased muscle tone). This happens in case of damage to the central nervous system, impared ability of damaged motor neurons to regulate decending pathways gives rise to disordered spinal reflexes. Contractures are a common and debilitating problem for individuals who have suffered from neurological or orthopedic injuries. weakness, Decreased motor control, sensation, and spasticity renders the affected hand immobile which further leads to limited functional usage and learned non-use. This is referred to as mucle-death or muscle-atrophy.

This can be seen in stroke patients from lower sections of society, with little or no access to a physiotherapy centre.

In their case due to lack of movements of the fingers over a prolonged period of time (around 1-2 years) they develop contractures.

Although not rare in case of stroke patients, this is more commonly seen in burns patients, due to the charring of the skin and consecutively the regrowth, contractures start forming. [14]

Image :Hand having contracture Source: https://www.saebo.com/contracture/

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Biomechanics of a human hand.

Clinical assessment of the hand of a stroke patient

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A. Understanding the human hand And how it changes after stroke

Some biologists believe that the development of the human hand contributed to the development of a large and complex brain. The hand’s very existence potentiated brain development by allowing humans to manipulate, interact with, explore, and gain information from their environment.

Development of a more complex brain permitted us in turn, to make and use tools and to develop language, which in turn led to the growth of an elaborate system of shared meanings, what we know as culture.

After the brain, It is considered as one of the most complex organs in the body. With improper functioning of even one hand, we would face issues doing basic tasks like drinking a glass of water; this inability can further demoralise stroke patients and slow down the pace of recovery.

Although before we go into the details of a hemiplegic hand, we must understand the functioning of a ‘normal’ or fully able hand. [16]

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Nerves that innervate muscles of the hand

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The three arches of the hand maintain balance, stability and mobility of the hand. The proximal transverse arch is rigid, but the other two arches are flexible, and are maintained by activity in the hand’s intrinsic muscles.

Like mentioned earlier, after a stroke, damage to the brain can block messages between muscles and the brain causing arm and leg muscles to cramp or spasm (spasticity), kind of like a bad charley horse.

Intrinsic and extrinsic muscles of the forearm: “E/I” refers to “extrinsic” or “intrinsic”. The intrinsic muscles of the forearm act on the forearm, meaning, across the elbow joint and the proximal and distal radio-ulnar joints (resulting in pronation or supination), whereas the extrinsic muscles act upon the hand and wrist. In most cases, the extrinsic anterior muscles are flexors, while the extrinsic posterior muscles are extensors.

The brachioradialis, flexor of the forearm, is unusual in that it is located in the posterior compartment, but it is actually in the anterior portion of the forearm.

The anconeus is considered by some as a part of the posterior compartment of the arm.

After stroke the nerves of the limbs get little to no signal which means the muscles such as the Flexor carpi ulnaris, abductor pollicis etc. don’t get any impulse from the ulnar nerve. [15]

Graduation Project | Design of an upper limb assistive device for stroke patients

Image IIA.1: Motorneuropathies of the upper extremity Source: https://neupsykey.com/mononeuropathies-of-the-upper-extremities/

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Image IIA.2: Motorneuropathies of the upper extremity Source: http://teachmeanatomy.info/upper-limb/muscles/hand/

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Image IIA.3: Motorneuropathies of the upper extremity Source: https://neupsykey.com/mononeuropathies-of-the-upper-extremities/

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Wrist and finger joint movements: The large number of bones in the hand and wrist makes for a large number of joints, too. In order to get to speak to a lot of therapists and patients I had to educate myself regarding the the different joints and muscles that help you move your wrist, wave your hand, and wiggle your fingers.

To assess the magnitude of impact to which the stroke has affected the patient’s hand movements, I had to find out the degree of voluntary movement in the hand. To start with, there are 3 main ranges of motion for the wrist; namely Supination & Pronation, Ulnar & Radial deviation and Extension & Flexion, as shown in Image .

Image IIA.4: Movements of the hand Source: http://www.healthcaretimes.com/news/

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B. Patient Assessment For this I visited Mr. Rajesh at the PMR Dept. at Dr. RML Hospital, he helped me understand the process with which they assess a stroke patient. This not only referred to the understanding of different hand movements and how they were graded qualitatively or quantitatively but also referred to how such patients were to be approached and dealt with.

Although, just as a master first gauges the level of dedication of his apprentice; he first asked me to assess a patient on the basis of my understanding in order to gauge the level of my emmersion in this project.

With great help from Dr. Jyoti Gupta, Neurologist at Dr. RML Hospital I was given a chance to assess 6 hemiplegic stroke patients under her supervision. With some help I was successfully able to examine the stroke patients and interview them regarding their problems in using their hands.

Image IIA.5: Getting used to interactions with patients and therapists

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Resting position of a normal hand There are few basic hand movements of an able hand that one must understand before assessing a patient and understanding the deficiency in those movements after stroke. These include; Functional position of the hand: (Norkin & Levangie, 1992, p. 296; Hertling & Kessler, 1996, p.

260)

Wrist extended 20 degrees ulnarly deviated 10 degrees

Digits 2 through 5 MP joints flexed 45degrees PIP joints flexed 30-45 degrees DIP joints flexed 10-20 degrees

Thumb first CMC joint partially abducted and opposed MP joint flexed 10 degrees IP joint flexed 5 degrees When therapists immobilize a patient’s hand, they often position it this way. During a period of immobilization, the resting lengths of the hand’s ligaments and muscles change. This hand position provides the best balance of resting length and force production so the hand can function when the patient mobilizes it again.

Image IIB.1: Sketch of a normal hand

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Resting position of a spastic hand After stroke, when the patient is in the 3rd and 4th Brunnstrom stage, as mentioned previously, he develops spasticity in the limbs of the affected side. This means there is a tendency of certain muscles to contract due to a lack of or irregularity in the signal transmitted from the nerves.

Clinical examination/ assessment helps distinguish between spasticity and contracture.

Position of hand in case of spasticity: When severe, this tight position may generate hygiene problems: unpleasant sweating, maceration, and even skin ulceration.

Wrist Flexed Supinated

Digits 2 through 5 MP joints flexed 30degrees PIP joints flexed 90 degrees DIP joints flexed 90 degrees

Thumb first CMC joint abducted and flexed MP joint flexed 80 degrees IP joint flexed 90 degrees

Image IIB.2: Sketch of a spastic hand

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Spastic hands chosen for study Very often, the elbow is permanently flexed during activities (walking, running, activities with the contra-lateral hand), but can relax and extend at rest. Sudden stimuli such as a loud noise, pain‌ may cause it to flex even more. Clinical examination helps to distinguish between spasticity, which can be overcome by gentle but firm prolonged traction in extension, and muscle contracture which does not give way. When severe, this deformity makes use of the hand almost impossible.

But there are other patterns, for example the elbow can be permanently straight, fully extended, which renders most activities of daily living even more difficult, or impossible (feeding).

The two marked hand positions are the one seen most prominently in stroke patients. They can be closed, making a tight fist around the thumb, which is clenched into the palm. This position renders the hand useless.

If there is only spasticity and no contracture, the fingers can usely be progressively brought into passive extension with firm but gentle traction. But the deformity soon recurs within a few minutes. When severe, this tight position may generate hygiene problems: unpleasant sweating, maceration, and even skin ulceration. [16]

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C. Empathetic Study Stepping into the shoes of a stroke patient

I recalled a small workshop I had attended in callege titled ‘Design for Dignity’, in that one day workshop we were asked to design a kitchen equipment for visually impaired persons and before doing so we were blindfolded and asked to work with a knife and stove. This helped us understand in greater depth the situation and the people we were designing for.

Similarly, to better understand the plight of the patients I was studying, I decided to tape up my hand for a day in order to restric its function the same way a stroke person’s hand function might be restricted. Although this led to moments of frustration, confusion and despondency, it contributed greatly in my interactions with the patients and therapists, making it easier for me to connect with them.

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The flexed fingers, along with the thumb in adduction made it very hard to hold onto any object. If either of the two were feasable, a partial grasp would have been possible but this wasn’t the case.

Besides this I felt highly uncomfortable with my fingers scrunched-up. My thumb was sweaty and my palm was itching due to the stiff position and lack of movement.

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Study of spastic hands: From my observations I noted that In the case of moderate to severe spastic hands there is still certain degree of improvement in the scapula, shoulder, elbow and wrist although finger joints and metacarpophalagial joints (MCP/ MC joints) rarely recover voluntary movement.

Although since the muscles supplying these joints are active and so passive movement (movement with the help of unaffected arm, caretaker or therapist without voluntary effort) is possible. Active movement (movement of the affected arm performed voluntarily by the patient) is always encourged but it can take from six months to ten years to a lifetime for the patient to regain this movement.

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D. About Sawan & his family: In any design project the most satisfying experience is having an eagerly participative user because

without the user, the design is simply a piece of art.

After my initial research at Amar Jyoti where I first saw Sawan , I got busy in doing further research, visiting RML hospital and seeing other patients. In between this time I received a call from Sawan’s father asking me if I was done with my design and if he can purchase it and he even enquired about the price!

After hearing this I told him the product was still under development and asked him if he would like to help me in the development; he agreed.

He worked with me throughout the duration of the product development. His father was also a big help in understanding the issues he faced at home and how he tried to overcome them.

He had a stroke on May 26, 2016. Ever since then he has been visiting Amar Jyoti Physiotherapy centre for rehabilitation. He regularly went for therapy in the morning from 9am-10am and would go to his office straight from there.

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His father is an auto-driver and his mother is a teacher, both have worked very hard to make life comfortable for him.

Just around the time when he had a stroke his parents were looking for a match for him, they were very devasted to find out the long-term effect this disorder would have on him.

A year and two months after the attack Sawan rejoined his office. He worked at Wipro in Noida, due to the nature of his illness they had given him paid leave for a certain duration.

Initially he was a little hesistant to talk to me but after 4 visits it got better..

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Velcro straps for the fingers

Flattened support to hold fingers in extension

Support for the thumb

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Velcro straps for the arm

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Static Splint Rehabilitative Device: For reducing spasticity Sawan got this splint made at Amar Jyoti Prosthetics and Orthotics workshop itself, on the recommendation of a physiotherapist there.

He has been advised to wear this at night just before he goes to sleep and for 30 minutes during the day. Research shows that spasticity may vary slightly depending on factors such as stress levels, temperatures and other environmental factors.

For this reason he is advised to wear this splint that ensures that his fingers stay entended and wrist neutral if his spasticity reduces at night. By doing this the therapist is trying to make sure his extensors of the affected arm don’t atrophy owing to the constant flexed state his spastic hand assumes.

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Spring to facilitate extension Finger caps MP stop (to prevent fingers from hyper-extension)

Foam padding

MS powder coated base for support

Velcro straps for the arm

800

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Dynamic Splint Rehabilitative device: finger and wrist extension The dynamic splint is supposed to keep the fingers in a constant state of extension so as to exercise the muscles and avoid muscle death. This is for purely rehabilitation purposes.

Sawan’s father had purchased this splint from Bhagirath Palace in Chandni Chowk in a desperation to get something that would help with the extension of his fingers. Although it was a very cheap device, it didn’t serve its purpose due to the bad design. The placement of springs doesn’t help in the extension of the fingers, his father tried to modify the springs by extending or cutting them but it didn’t help. Overall he was quite let down by this experience and this had been lying in the cold storage of his house ever since.

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Inferences.

Interacting with the patient and his family I realised how help-less they are.

The devices that are in the market haven’t yet reached the users and that makes me wonder why?

Mere observation of the user and his context can teach you much more than any questionnaire.

A lot was learnt after observing Sawan in his therspy sessions. Not only the physical problems faced by him but also the psychosomatic effects the disorder had on him.

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Problem statement.

To Design a device for stroke patients that allows variable finger extension.

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Graduation Project | Design of an upper limb assistive device for stroke patients

Understanding the market.

Clinical assessment of the hand of a stroke patient

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My Journey so-far After establishing the background of the condition in order to move forward I decided to first do desk research on the problem area and before proceeding for field research; make a quick mock-up of an idea.

Through my experience in previous classroom projects I came to realise that users/ stakeholders respond better to tangible objects that simple, straightforward questions.

Keeping this in mind I made a quick mock-up with the materials available to me in order to have more fruitful conversations with the shopkeepers, workshop technicians or the physiotherapists I had planned to meet.

The sole purpose of this mock-up was to start a meaningful debate on the topic with whomsover I was going to meet.

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A. Desk Research: Assessing gaps I studied a variety of devices to better understand the gap in the market I can fill. There are broadly two types of devices that exist in the market; ones that assist the patients in doing certain tasks and ones that are rehabilitative , which are aimed at improving the state of the affected arm.

While assistive devices help the patients do certain tasks they often undermine the importance of maintaining the dignity of the patient. While these kind of devices, for example the Eating Assistance help the patient in eating his food, neither is it is helping him eat the way he used to before nor is it helping in the improvement of his hand function.

The other type of devices are rehabilitative, such devices aim at improving the condition of the affected hand. While such devices (such as Bioness H200) serve their purpose in a setting such as the physiotherapy centre, they fail at the time when the patient gets back home and wishes to pour himself a glass of water.

Rehabilitation is an awefully slow process and they require an intervention that assists them when they are home and in that process aids rehablitation as well.

-Where my intervention lies

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B. Saebo Flex SaeboFlex is a high profile, out-rigger style splint, this type of a unique orthoses positions the wrist and fingers into extension and in preparation for object manipulation. It works on the basic mechanism of extension using springs with extension springs attached to the different chords leading to the fingers.

The user is able to grasp objects by voluntarily flexing his or her fingers.

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Once the fingers relax (stop gripping), the extension spring system assists in re-opening the hand to release the object.

This kind of a device helps in opposing the spasticity and initiated a small degree of active movement in case of moderate to severe stroke cases. [17]

Graduation Project | Design of an upper limb assistive device for stroke patients

Although Saebo Flex has been marketed as a rehabilitative device it claims to also help the user do certain tasks. The effectiveness of this device is questionable because of the usability issues it poses:

2. Using springs for a mechanism is never the most durable option. In case this device is used by a stroke patient with a high level of spasticity the springs would lose their tension pretty quickly and will have to be replaced by the patient.

1. The device by itself is made up of too many smaller parts-the finger caps, extension that rests on the posterior of the palm, the thumb extension with the thumb cap and the main body that rests on the arm. This makes the donning of the device complicated and the help of a second person is required to put it on (noted from personal experience with the device).

3. The design of the finger caps isn’t universal and would be hard to wear, in case of a severely spastic hand.

4. The rigid form of the shell indicates that one such device can only be used by patients with that particular hand and finger size. This would not only be problematic for the therapy centre to purchase many different sizes but also cost a lot to manufacture every single size separately.

SAEBO FLEX IS HELPFUL IF YOU WANT TO PICK UP A SPONGE-BALL OFTEN!

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C. Bioness H200 This is a Functional Electrical Stimulation (FES) based device. Bioness H200 consists of an electronic orthosis and its control unit. The control unit transmits synchronised electrical pulses to the periferal nerves of the hand through electrodes built into the othosis. These pulses consistently activate different muscle groups of the forearm and hand.

It was designed to provide proprioceptive input in synchronised muscle activity. These movements may fascilitate normal patterns leading to the reversal of learned non-use. [18]

Electrical stimulation or neuromuscular electrical stimulation (NMES) is a technique used to elicit a muscle contraction using electrical impulses. Electrodes, controlled by a unit, are placed on the skin over a predetermined area.

Electrical current is then sent from the unit to the electrodes and delivered into the muscle causing a contraction.

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By seeing the different picture of Bioness H200 in use we can see that it was marketed as an assistive device that can help a patient in performing a vareity of tasks.Although with a little more research we realise that it functions in a rhythmic manner; ie. the respective electrodes in the device get activated for a fixed duraton. This means if it is set at 3 seconds the user would have the perform the grasp function within 3 seconds etc.

Some other loopholes in the design were: 2. It costs a bombshell. Considering its design such a device will most probably be purchased by a therapy centre or a therapist, even in that scenario one would have to purchase a range of devices of this type to help all the patients visiting the clinic.

3. More rehabilitative than assistive. Like mentioned earlier, the working of this device suggests that it is more rehabilitative than assistive.

4. The form is very critical because the placement of the electrodes is crucial for it to work properly. With different hands having different forms I suspect whether it would work for same hand sizes as well.

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D. Exo Glove Poly Exo-Glove Poly is a soft wearable robot that addresses paralysis of the hand by enabling people to grasp and pinch various objects. Built so that it’s comfortable enough to be worn every day and waterproof for easy sanitisation,

Thumb support Wrist buckle Finger caps Tendon Tendon supports Tendon cover

Magnetic clasp

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It has three fingers that fit over the wearer’s thumb, index finger and middle finger, with a soft tendon routing system of wires. The motor, controlled by a simple switch, pulls on the wires to open and close the hand. [19]

Functions of Exo-Glove Poly:

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Min. point of elasticity Least possible elastic force No voluntary extension

Max. point of elasticity Greater elastic force Better voluntary extension

E. Mock-up A.V1 Concept for variable finger extension My first concept was aimed at providing variable finger extension options. The idea was that one device provides the user a chance to opposing force applied for the extension of the fingers.

During the initial stages according to Brunnstrom, more amount of force is required to extend the spastic fingers but as the patient progresses in terms of stages, voluntary movements return and lesser amount of force is required to extend the fingers.

The coloured scale represents the degree of recovery (red being poor and green being good).

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1. Suitable for different levels of spasticity The idea is that this device be kept with the physiotherapist and given to the patient every 2 months or so. This will help motivate the patient.

2. To make it interactive for patients When they play around with it they will end up initiating movement in the fingers of their affected arm, therefore avoiding muscle atrophy.

Sketch: Donning the device-in steps

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Finger caps Button-hook

Rubber band for finger extension

Runners for rubber-band

Hand sleeve Elastic for better hold on finger

Button to fix position of extension

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F. Visit to PMR Department, RML Hospital, Delhi With help from my mother I was able to interact with the therapists in the PMR Dept. at RML Hospital. I wanted to understand from them how much they knew about the existing devices since they are the point of contact for the stroke patient.

As seen in the PCP illustrated earlier we can see that the therapist plays a major role in the rehabilitation of the patient post stroke. The use of any medication or device is advised to the patient by the therapist.

The therapist at RML showed me this refernce book (see image) that they consulted for such devices. This was published in 1995 by an American company called Smith and Nephew Roylan Inc. Each of these devices were designed to assist with a very specific task. For example, eating with a fork, buttoning your shirt, putting on your shoe etc.

The sole purpose of such devices is to help you do a certain task, they aren’t concerned with the affected arm per say. Now one would wonder if you’d be expected to move around with a bagfull of such devices!

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G. Visit to Chandni Chowk, Delhi I was curious to find out what I could actually buy if I were a stroke patient, I had heard from the lab technicians at AIIMS that Bhagirath Palace in Chandni Chowk was the place to find the latest pre-fabricated splints and other medical devices.

This led me wandering into the tiny yet expansive gullies of Chandni Chowk. I was able to find many stores selling latest surgical equipments and prosthetics but wasn’t able to find anything exciting that catered to my need. Although it wasn’t a wasted effort, because this meant I was working on something very relevant.

I was only able to find one exercise device that was designed so terribly that it wasn’t seving its purpose. It was aimed at maintaining the fingers in extension but wasn’t able to do so as can be seen in the picture.

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H. Visit to Healthy Future, Ahmedabad With the help of Mr. Sachin from the PMR Dept. at RML, I managed to get in touch with Mr. Rashmikanth Shah from Healthy Future, Advanced Physiotherapy & Neuro Rehabilitation Centre. I learnt from him that it’s important to understand the level of spasticity in the patient’s hand to assist him. He has had exposure to the kind of treatments and support provided in foreign countries. He came to realise that although a lot of experimentation has happened in designing rehabilitative or assistive devices in other countries, the price range is highly unrealistic. One such device is Saebo Flex, it is a rehabilitative device that is priced at aroud 2 lakhs!

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I. National Design Incubation Centre, Ahmedabad Here I met the founders of the start-up Limbot. This is a company creating affordable hand prosthetics, they have already developed the first prototype and it’s selling for 15 thousand.

They had also inferred from their research that there is a need for affordable rehabilitative devices in India.

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Inferences.

The concept was more rehabilitative than assistive. That market is already crowded.

The thought behind the concept was to make the users more independent. Although the design maintains the hand in a constant state of extension, rendering it useless in case of a highly spastic hand.

Not much existed in the assistive device market that was also rehabilitative After visiting a variety of stakeholders I realised that if a 2nd-5th stage stroke patient needed a device to help him use his hand he didn’t have any optons.

Existing cheap assistive devices aren’t bought by patients The existing devices (eg. strap on fork to help stroke patient stab into food and eat) didn’t help as much and wasn’t adviced by the therapists.

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Brief.

To Design an assistive device for hemiplegic stroke patients to help them do some basic bi-lateral tasks and also helps in the rehabilitation of the affected hand.

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Concept Generation.

With the background work complete it was now time to work on the foreground. It was time to do some ‘making’.

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A. Concept B.V1 Concept for Light weight exoskeleton This was an initial concept for a alight weight exoskeleton.

The finger caps would be wrapped around and the force of repultion between two magnets would maintain fingers in the extended position.

Different forms of were explored of the path along which the force of extension is applied on the fingers.

I wanted to explore different ways in which I could have extension of the fingers without a spring which would dampen over a period of time.

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B. Mock-up C.V1 Concept for Universal frame design After studying a variety of devices I came to the conclusion that a universal design was needed. There was a need to make the form such that it could be worn by patients withing a large range of hand sizes.

The idea was that the caps and cords can be sold seperate from the main body of the device.

This was an issue I had seen prominently in Bioness H200 (Also because Functional Electrical Stimulation (FES) technology demands precision in points of contact with patient’s arm), in Saebo Flex (In this case not only the main body but the caps are also less universal owing to their form) and also in the prefabricated splints where the frame is made of either formed plastic or aluminium and falls on the contours of the hand such that one size wouldn’t fit all.

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C. Some failed attempts Due to form, functionality or material The idea was to play around with material and form and hopefully arrive at something interesting.

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2. To make the device thinner This didn’t work, also because I had used OHP sheet which was quite rigid.

1. Rubberbands were used to fasten the section to the finger This didn’t work because a spastic patient’s finger is usually shut tight.

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Revised Brief.

To Design an assistive device for hemiplegic stroke patients with low, medium or high level of spasticity that can help them do some basic bi-lateral tasks and also helps in the rehabilitation of the affected hand.

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D. Task Flow with Sawan After studying the movements of a spasti and an able hand the task flow analysis was done for a user using Sawan.

A basic bi-lateral task was studied; such as ‘Pouring a glass of water for yourself and then drinking it.’ The objective was to use the unaffected arm to trigger the device and then leave it free to participate in the task. Many existing designs use the unaffected arm to trigger the device although that fails because the affected arm should be used only in case of bi-lateral hand movements and not as a dominant hand.

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#1 Spastic hand in the relaxed position.

#2 Functional hand opens fingers of spastic hand for donning of device.

#3 Functional hand puts the plastic cap on thumb of spastic hand.

#4 Functional hand puts the plastic caps on fingers of spastic hand.

#5 Functional hand taps on the button of the device.

#6 Fingers and thumb of spastic hand open up with the help of the device.

#7 Spastic hand opens up fully.

#8 A water bottle and glass are kept on the table.

#9 Functional hand reaches out for the bottle, spastic hand in extension.

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#10 Motor releases the chord leading to the flexion, passive or active, of the fingers and the thumb of spastic hand.

#11 Functional hand opens up the cap of the bottle while the spastic hand holds it.

#12 Spastic hand tilts bottle to pour water while functional hand holds the glass.

#13 Functional hand closes the cap of the bottle while spastic hand has still gripped it.

#14 Functional hand again taps on the button of the device to initiate finger extension of fingers of spastic hand.

#15 The device opens up the spastic hand.

#16 A switch gets triggered when the fingers of spastic hand reach full extension and device releases the chord.

#17 This release of the chord brings the fingers of the spastic hand back to flexed/relaxed position, naturally.

#18 Hands are back to their original relaxed states.

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E. Prototype 1.V1 : I started by making a dynamic splint same as the one made at the AIIMS prosthetics and orthotics workshop and then making modifications.

Step #1: The pattern was cut out of a PP sheet of 2mm thickness based on my Left hand dimensions.

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Step #2: The points of the bends were marked and made using a heat blower.

Graduation Project | Design of an upper limb assistive device for stroke patients

Step #3: For some bends talcum powder was applied in order to cool down the PP sheet faster and make it smooth.

Image : After few failed attempts, frowns and Feroz’s bhai’s laughs I was able to work with PP(Poly Propylene) and start work on the first prototype.

Step #4: The spring was put in place, the velcro straps were attached and the required holes were drilled.

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F. Experiments with mechanisms Mechanisms were explored for easy donning & doffing, regulated step-wise extension to prevent hyperextension of fingers and triggers.

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Image : The CAM is rotating, leaves the lever loose. Lever pushed back by a spring (not shown in the picture).

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Image : CAM pushes the lever, helping the lever slip the cord from the pulley.

G. Motor movement Motor direction and timing I tried to work out the mechanisms and the design of the mounting of the motor. This was done with the help of my father and Mr. Feroz from AIIMS hospital.

SOLENOID CONCEPT-Motor assembly break-up : I tried to sketch out the assembly of the motor allong with the other parts needed for its assembly but I didn’t go forward with this concept because of how complex it was becoming.

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H. Improvements The motor was attached to the skeleton of the device. It was attached such that the weight of the motor was balanced comfortably.

Although this position was changed later because the angle of movement didn’t work out. The front support for the finger chords was cut and replaced to improve finger movement.

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Finger caps: Different forms were tried for the finger caps and one was selected on the basis of flexibility of use, comfort and intuitiveness.

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The finger caps and the chord was attached to the skeleton created previously and then the circuit for the motor was created and mounted.

Step #1: The caps were placed on the finger, the device was strapped on and the motor was switched on. Finger flexed, wrist in pronation and partially flexed.

Step #2: MP joint in extension, wrist in extension and pronated.

Step #3: Wrist extended and pronated, the finger is almost fully extended.

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Learnings from mock-up 2.V1 The decision to first make the prototype of my hand size was a good one. This way after having a fair understanding of the type of hand movements presented in a spastic hand I could first make test and make changes on my hand itself.

There were a couple of issues that were identified and would have to be corrected for the next one made to Sawan’s hand size. These were: 1. The placement of the motor was decided as such for better weight distribution although it wouldn’t have worked for the purpose of testing. The force of extension was applied along the perpendicular direction, this puts a lot of stress on the motor.

2. The finger caps would have to be redesigned to suits a bigger finger.

3. A potentiometer had to be added to regulate direction of the motor.

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I. Prototype 1.V2 Sawan’s hand-size WIth the help of Mr. Feroz and by making changes to the pattern that he had developed for a generic hand, I deveoped Proto 2.V2 made to Sawan’s hand size.

I also made few changes in this one as opposed to Proto 2.V1.

These were: 1. Simpler contours (easier to shape and work with) 2. Improved position of the motor: It was now placed such that the chord running over the motor shaft will fall directly in line with the hole leading to the fingers.

3. The form of the finger caps was improved, easier to put on and made adjustable to the different fingers.

This prototype took one month to develop, after which I took it to Sawan for testing.

Step #1: Sawan’s left (functional) hand was traced on paper to get the right measurement. Then I made few modifications to the pattern that was created by Mr. Feroz at the AIIMS workshop and drew the final desired silhouette of the structure.

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Step #2: The traced silhouette was cut out and the mirrored shape was used (since Sawan’s RHS is affected). After confirming the shape of the silhoutte on his hand the markings were made for further cuts and the direction and extent of bends was also marked. The markings were made for part#1.

Step #3: Same as Step #2. The prototype consisted of 2 parts.

The markings were made for section 2.

Step #4: The sections were placed on the patient’s hand to confirm the size. Appropriate hole positions for the chords were marked.

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Step #5: The hole positions were checked by fitting the parts on the patient’s hand. Confirmation was received from the therapist at Amar Jyoti regarding the position of the hinge.

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Step #6: The rough bends were finished. Minor changes were made in the finishing and bending of certain sections.

Graduation Project | Design of an upper limb assistive device for stroke patients

Step #7: The markings were made on the motor to fit it onto the PP structure.

Step #8: The motor was fitted onto the structure. The straps were put the help of rivets.

Step #9: Thedesign of the caps and chord was finalised.

The caps were made such that they can fit different sizes of fingers.

Step #10: The motor assisted chord based extension mechanism was tested on Sawan’s hands with one finger gap.

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J. Sequence of hand movements with Sawan The sequence of movements was sketched and related to the intended movements that the electronic circuit would provide.

This was analysed in steps to better understand the programming/ wiring that would be required while making it.

Here P is the pulley and M is the motor. Clock-wise movement of the pulley indicates release of the cord and the natural flexion of the fingers while the anti-clockwise movement refers to the cord becoming taut and the fingers undergoing passive extension provided by the device.

On step #3, after reahcing the point of full exntension the pulley starts to rotate in the opposite direction (antilockwise) and winds the cord.

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Image IVC. :

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3D modelling Sawan Quick trial at 3D To better understand the form of the finger caps and the structure of the runners for the cords I made a basic 3D model.

This also helped me better visualise the final form that the device would take. Since the form is very organic (because it falls on a human hand), I used the reference of a 3D model of a hand to get a reference of the placement of the different structures and the look of the device

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Graduation Graduation Project Project || Design Design of of an an upper upper limb limb assistive assistive device device for for stroke stroke patients patients

Pulley Mid runner for support Potentiometer to vary motor speed Finger caps Hinge to allow wrist movement Velcro straps

Cord to extend fingers

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Graduation Graduation Project Project || Design Design of of an an upper upper limb limb assistive assistive device device for for stroke stroke patients patients

My onward Journey This prototype is still far from market-ready. Till now this would qualify as a proof of concept.

The iterative process is cumbersome and may seem endless and so it took time to resolve the smallest of problems.

Some usability issues I plan to resolve in the future are: 1. Easy donning and doffing 2. Convenient size of motor (currently an affordable yet powerful motor was used, I’m sure there are better alternatives available) 3. Safety mechanism for return of cord from max. point of extension 4. Based on my previous exploration, I would like to create a better form such that it is universal and occupies lesser volume on the shelf.

5-10,000 (Approximation only)

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Learnings I believe my interest in this field started from when I was a little child, I was always intrigued after my visits to the hospital and enjoying talking to them and learning about different conditions.

I would say that this project gave me a taste of what product development would be like. It isn’t as easy as making a render or a sketch, it requires a lot of patience and a lot of belief in what you are doing.

When I decided to go forward with this project I purely thought of it as a new experience. SInce I didn’t have a proper workshop I thought it would end up being a hypothetical concept, restricted to the pages of my graduation document.

Had it not been for the patient who was eager to have such a device, I wouldn’t have put in this much effort in its development.

Through the course of this one year I also learnt how to be a more dynamic designer. It is important to be open to change and new ideas, specially if you are working with people from different professions. I learnt how design is understood by doctors, therapist, manufacturers and the petient himself.

By the end of this project I learned to see design differently.

I got to experience the side of design that I didn’t get a chance to, in college.

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Way Forward At this stage, the proof of concept needs a lot of refinement. I plan to move forward with it because I would love to take this product to a level such that I can give it to Sawan.

Stroke if a fairly common disorder and I want Sawan to reach as many people as would be possible. For this I would have to create an ecosystem such that the product can be developed.

In the next few years I hope to gain enough expertise to take this forward and hopefully commercialise this product.

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References (Websites): 1. THE BRUNNSTROM STAGES OF STROKE RECOVERY | SAEBO (Saebo, 2017) Saebo. (2017). The Brunnstrom Stages of Stroke Recovery | Saebo. [online] https://www.saebo.com/the-stages-of-stroke-recovery/ [Accessed 23 Apr. 2017].

2. HISTORY OF STROKE | JOHNS HOPKINS MEDICINE HEALTH LIBRARY (Hopkinsmedicine.org, 2017) Hopkinsmedicine.org. (2017). History of Stroke | Johns Hopkins Medicine Health Library. [online] https://www.hopkinsmedicine.org/healthlibrary/conditions/ nervous_system_disorders/history_of_stroke_85,P00223 [Accessed 11 Apr. 2017].

3. STROKE - SYMPTOMS AND CAUSES - MAYO CLINIC (Mayoclinic.org, 2017) Mayoclinic.org. (2017). Stroke - Symptoms and causes - Mayo Clinic. [online] https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc20350113 [Accessed 11 Apr. 2017].

4. PADMANABHA, A. ‘India in midst of stroke epidemic’ (Health Feature) (Padmanabha, 2017) Padmanabha, A. (2017). ‘India in midst of stroke epidemic’ (Health Feature). [online] Business-standard.com. http://www.business-standard.com/article/news-ians/ india-in-midst-of-stroke-epidemic-health-feature-114020400288_1.html [Accessed 12 Apr. 2017].

5. WHAT IS STROKE? (Stroke.org, 2017) Stroke.org. (2017). What is stroke?. [online]http://www.stroke.org/understand-stroke/what-stroke [Accessed 14 May 2017].

6. USER, S. spastic-hand || Spastic upper limb (User, 2017) User, S. (2017). spastic-hand || Spastic upper limb. [online] Spastic-hand.com. http://www.spastic-hand.com/index.php/en/spastic-upper-limb [Accessed 6 May 2017].

7. SAEBOFLEX | SAEBO (Saebo, 2017) Saebo. (2017). SaeboFlex | Saebo. [online] https://www.saebo.com/saeboflex/ [Accessed 5 Apr. 2017].

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8. BIOMECHANICS OF THE HAND (Ouhsc.edu, 2017) Ouhsc.edu. (2017). BIOMECHANICS OF THE HAND. [online] http://ouhsc.edu/bserdac/dthompso/web/namics/hand.htm [Accessed 24 Jun. 2017].

9. UCL NICK WARD - UPPER LIMB (Ucl.ac.uk, 2017) Ucl.ac.uk. (2017). Cite a Website - Cite This For Me. [online] https://www.ucl.ac.uk/cnr/docs/upperlimb/ward [Accessed 12 Jun. 2017].

10. AMAR JYOTI CHARITABLE TRUST :: NGO IN DELHI, AMAR JYOTI REHAB CENTER DELHI (Amarjyotirehab.org, 2017) Amarjyotirehab.org. (2017). Amar Jyoti Charitable Trust :: NGO in Delhi, Amar Jyoti Rehab Center Delhi. [online] http://www.amarjyotirehab.org/ [Accessed 2 Sep. 2017].

11. AIIMS - ALL INDIA INSTITUTE OF MEDICAL SCIENCE (Aiims.edu, 2017) Aiims.edu. (2017). AIIMS - All India Institute Of Medical Science. [online] http://www.aiims.edu/en.html [Accessed 2 Aug. 2017].

12. SPASTICITY (Strokeassociation.org, 2017) Strokeassociation.org. (2017). Spasticity. [online] http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/ Spasticity_UCM_309770_Article.jsp#.WftD-2iCxPZ [Accessed 29 Jul. 2017] 13. NCBI (Stroke.org.uk, 2017) Stroke.org.uk. (2017) [online] https://www.stroke.org.uk/sites/default/files/state_of_the_nation_2017_final_1.pdf [Accessed 6 Aug. 2017].

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References (Papers/ journals): 1. Haemin Lee, Brian Byunghyun Kang, Hyunki In and Kyu-Jin Cho, 2016, Wearable Robotics: Challenges and Trend ,Design Improvement of a Polymer-Based Tendon-Driven Wearable Robotic Hand (Exo-Glove Poly, Springer, Pg. 95-96 2. Byungchul Kim, Hyunki In, Dae-Young Lee and Kyu-Jin Cho, 2017, Development and assessment of a hand assist device: GRIPIT, Journal of neuroengineering and rehabilitation, Pg. 1 3. Emma Court, 2016, High-Tech Tools Show Promise for Stroke Recovery, The Wall Street Journal, Pg. 2 4. Duncan PW, Goldstein LB, Matchar D, Divine GW, Feussner J. Measurement of motor recovery after stroke: outcome assessment and sample size requirements. Stroke 1992;23:1084–1089 5. Wade DT, Langton-Hewer R, Wood VA, Skilbeck CE, Ismall HM. The hemiplegic arm after stroke: measurement and recovery. J Neurol Neurosurg Psychiatry 1983;46:521– 524

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Citations (Websites): 1. Stroke. (2017, August 15). Retrieved April 02, 2017, from https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc20350113 2. Nall, R. (2016, March 21). History of Stroke. Retrieved April 10, 2017, from https://www.healthline.com/health/stroke/history-of-stroke 3. Functional electrical stimulation (FES). (n.d.). Retrieved June 13, 2017, from https://www.mstrust.org.uk/a-z/functional-electricalstimulation-fes 4. (n.d.). Retrieved May 13, 2017, from https://www.sciencedaily.com/releases/2013/05/130508122841.html 5. Spasticity. (2017, April 12). Retrieved July 10, 2017, from http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-strokeconditions/physical/spasticity 6. What Is Contracture. (n.d.). Retrieved July 24, 2017, from https://www.saebo.com/contracture/

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Citations (Papers/ journals): 1. Gourie-Devi, M. (2014). Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy, stroke, Parkinsons disease and tremors [Abstract]. Neurology India, 62(6), 588. doi:10.4103/0028-3886.149365 2. Yeung, K., Lin, C., Teng, Y., Chen, F., Lou, S., & Chen, C. (2016). Use of and Self-Perceived Need for Assistive Devices in Individuals with Disabilities in Taiwan. Plos One, 11(3). doi:10.1371/journal.pone.0152707 3. Kim, B., In, H., Lee, D., & Cho, K. (2017). Development and assessment of a hand assist device: GRIPIT. Journal of NeuroEngineering and Rehabilitation, 14(1). doi:10.1186/s12984-017-0223-4 4. Pandian, J. D., & Sudhan, P. (2013). Stroke Epidemiology and Stroke Care Services in India. Journal of Stroke, 15(3), 128. doi:10.5853/ jos.2013.15.3.128

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Appendix: 1. Ulnar: Pertaining to the ulna; the bone of the forearm on the side opposite to the thumb.

2. Radial: Pertaining to the radius, the smaller bone in the forearm 3. Spasticity: It refers to a condition in which certain muscles are continuously contracted.

4. Intrinsic: Situated within or belonging solely to the organ or body part on which it acts.

5. Extrinsic: Originating outside a part and acting on the part as a whole.

6. Dorsal: Being or located near, on, or toward the upper surface of an animal.

7. Palmar: Pertaining to the palm (the grasping side) of the hand.

8. Supination: Rotation of the forearm and hand so that the palm faces forward or upward.

9. Pronation: Rotation of the hand and forearm so that the palm faces backwards or downwards.

10. Extensor: A muscle serving to extend a bodily part (as a limb) — called also extensor muscle.

11. Flexor: A bending movement around a joint in a limb (as the knee or elbow) that decreases the angle between the bones of the limb at the joint.

12. Distal: Literally meaning “standing away from” is used for the part furthest from the point of attachment.

13. Proximal: Literally meaning “near” refers to the part of an appendage nearest to where it joins the body.

14. Abduction: Movement of a body part away from the median plane (of the body, in the case of limbs.

15. Adduction: Movement of a limb toward the midline of the body.

16. Hypotonia: Commonly known as floppy baby syndrome, is a state of low muscle tone.

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17. Hypertonia: Increased tightness of muscle tone and reduced capacity of the muscle to stretch caused by damage to the motor nerve pathways in the central nervous system.

18. Brunnstrom Stages: It refers to a theory developed by Signe Brunnstrom which categorises a stroke patient’s recovery into 7 main stages.

19. Atrophy: Decrease in size or wasting away of a body part or tissue; also :arrested development or loss of a part.

20. Flaccid: Paralysis in which muscle tone is lacking in the affected muscles and in which tendon reflexes are decreased or absent.

21. Synergy: Interaction of discrete agents (as drugs) such that the total effect is greater than the sum of the individual effects.

22. Synergy Patterns: A stable spatiotemporal pattern of activity across muscles simultaneously involved in the performance of a movement.

23. Tone: This refers to the state of slight contraction usually present in muscles that contributes to posture and coordination

24. Active movement: A movement that is effected entirely by the patient’s muscles, often with the guidance of the therapist.

25. Passive movement: Movement imparted to an organism or any of its parts by external agency.

26. FES (Functional Electrical Stimulation): Functional electrical stimulation (FES) is a technique that uses low energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system.

27. EMG (Electro Myography): This refers to a diagnostic procedure to assess the health of muscles and the nerve cells that control them (motor neurons)

28. Biofeedback: The technique of making unconscious or involuntary bodily processes (as heartbeat or brain waves) perceptible to the senses (as by the use of an oscilloscope) in order to manipulate them by conscious mental control.

29. ADL (Activities of Daily Living): The things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure.

30. Physiotherapy: A branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities.

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Graduation Project | Design of an upper limb assistive device for stroke patients

31. Haemorragic Stroke: This refers to bleeding or the abnormal flow of blood. The term “hemorrhagic” comes from the Greek “haima,” blood + rhegnumai,” to break forth; a free and forceful escape of blood.

32. Neuroplasticity: The brain’s ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.

33. Splint: A splint is a device used for support or immobilization of a limb or the spine.

34. C-bar: This is a static splint which holds the fingers in a ‘C’ shape position, hence known as C bar.

35. Posterior: It comes from the Latin word posterus, meaning “coming after”. Posterior is used as a technical term in biology and medicine to refer to the back side of things.

36. Anterior: Relating to or situated toward the front of the body.

37. Ischemia: Refers to the deficient supply of blood to a body part (as the heart or brain) that is due to obstruction of the inflow of arterial blood.

38. Stroke: The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain.

39. Contracture: A permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion.

40. Extension: An unbending movement around a joint in a limb (as the knee or elbow) that increases the angle between the bones of the limb at the joint.

41. Flexion: A bending movement around a joint in a limb (as the knee or elbow) that decreases the angle between the bones of the limb at the joint.

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