Robotics in Rehabilitation: Ankle Rehabilitation 1.

0 Introduction Rehabilitation robots could be broadly defined as robotic devices which cater for the rehabilitative needs of the disabled and elderly [1]. This definition could be interpreted to include assistive devices that are designed to provide disabled individuals with assistance in activities of daily living and devices that are used in physical therapy. The establishment of research and development in the area of rehabilitation robots could be dated back to the 1970s [2,3]. Trend in the literature indicated that earlier research were more focused on the development of assistive devices to assist disabled individuals in carrying out everyday tasks [2,3]. Since the 1990s, there were also publications which proposed the use of robots as aids for therapist working on physical therapy for patients suffering from neurological diseases [4,5,6] or musculoskeletal injuries [7]. This review will mainly concentrate on exploring the current state of technology for rehabilitation robots being used in the physical therapy context, with particular reference to ankle rehabilitation. 2.0 Importance of Robotics in Rehabilitation It is noted by some authors that ageing of the population is becoming a common phenomenon in many developed nations [6]. It is also well known that the elderly is more likely to suffer from neurological disorders such as stroke and that the survival rate is relatively high, thus creating a situation where motor rehabilitation is required to assist functional recovery of affected limbs[6]. This suggests that there will be growing demand for physical therapy and thus highlights the importance of the application of robotics in this field to reduce the burden placed on the physiotherapists. It was also proposed that through the use of robotic devices, rehabilitation training sessions could be made longer since one of the limiting factors of manual training is fatigue of the therapist due to the labour intensive nature of the task [8]. By having rehabilitation robots, the physical load could be taken off the therapist and it could even be possible for one therapist to supervise several patients at the same time, hence allowing better utilisation of the therapist's skill and also a reduction in cost [8]. The use of robots in rehabilitation also opens up the possibility for more accurate and repeatable control on the rehabilitation trajectory and force, hence making the outcome of therapy less reliant on the skills of therapists [8,9]. With the utilisation of robots, efficient collection of quantitative data on the training sessions could also be easily achieved, thus providing valuable information which could be used to evaluate the recovery progress [8]. The use of a robotic platform also means that interactivity could be built into training sessions through "games" in a virtual setting that provide visual feedback while also allowing patients to keep track of their own progress. This could prevent boredom and act as added motivation for the patient to carry out therapy[8]. 3.0 Ankle Rehabilitation 3.1 The Human Ankle The human ankle is a rather complex structure and is capable of movements in three degrees of freedom [10]. Figure 1 shows the different motion available at the human ankle. The ankle joint is responsible for dorsiflexion and plantarflexion motions [10]. The subtalar joint is involved in the inversion and eversion of the ankle while the transverse tarsal joint allows the abduction and adduction movements [10]. It should be noted that adduction-abduction motion is somewhat coupled with inversion-eversion motion [10]. An estimation of the range of motion of the ankle is

presented in Table 1 below. The ankle plays an important role in maintaining the stability of an individual during gait[10]. It must also be able to withstand impact and provide large forces during walking and running to push the body forward [10]. It was estimated that the maximum torque available at the ankle joint can range from 165 270Nm depending on the weight of the individual [11]. Yoon and Ryu had specified the required torque for an ankle rehabilitation robot to be at least 100Nm for plantarflexion, 40Nm for dorsiflexion and about 50Nm for inversion and eversion[12].

Table 1: Range of movement for ankle motions

Motion Dorsiflexion Plantarflexion Inversion Eversion Abduction Adduction

(Adapted from [13]) Figure 1: Motions available at the human ankle (Reproduced from [10])

Range of movement 25 50 40 25 30 30

3.2 Conditions Requiring Ankle Rehabilitation Physical therapy is often carried out to promote motor recovery for patients with neurological disorders such as stroke and spinal injuries [6,14]. Gait training is often done to promote recovery of motor functions in the lower limbs. One common problems for people suffering from neurological disorder is the inability to lift the foot upwards during the swing phase of gait, thus tripping the patient and disrupting the gait pattern by forcing the patient to take an alternative and "unnatural" trajectory to prevent tripping [15,16,17]. This condition is termed drop-foot gait and is brought on by the inability to control the affected muscle groups. It is often treated through the use of an ankle-foot orthosis which the patient wears around the ankle to prevents the foot from dropping excessively below the neutral position during gait [15,16,17]. Apart from preventing drop-foot gait, the range of motion and strength of the ankle must also be recovered if patients suffering from neurological disorders are to regain the ability for locomotion [14]. This is due to the important role the ankle plays in providing the propulsion force to move the body forward during gait and also its contribution in maintaining the balance of the individual. Ankle strain injuries caused by the stretching and tearing of ligaments at the ankle is also a common condition sustained during sporting activities and daily life [12]. Patients suffering from joint injuries would normally undergo therapy to regain range of motion and strength in the ankle once the damaged tissues are healed [18]. For athletes, the rehabilitation therapy should also begin as soon as possible and activity specific training is also required to ensure a fast and full recovery [18]. 3.3 Methods for Ankle Rehabilitation A structured rehabilitation regime is available for sprained ankle. Once the damaged tissues are healed, a series of rehabilitation exercises should be carried out to recover the functions of the ankle. The first stage of therapy involves exercises to restore the range of motion of the ankle [18]. This is followed by the strengthening of muscles around the ankle to prevent reinjury [18]. The strengthening exercises are primarily targeted at training of the peroneal muscles at the lower leg

and it is suggested that effectiveness of therapy can be increased through progressive addition of resistance in training [18]. Devices often used in this stage of training are ankle weights, surgical tubing and resistive bands [18]. Once full weight bearing capability is achieved, proprioceptive training should be done to redevelop balancing ability and postural control. This is generally done through the use of a simple device termed the wobble board, which consists of a circular platform attached to a hemisphere [18]. Generally, the patient is required to balance his or her weight on the platform while moving the inclination of the platform in a circular manner [18]. In the case of patients with locomotion problems due to neurological disorders, therapy to recover lower limb functions often includes body weight supported treadmill training [4] and a range of passive and active exercises to strengthen and improve the range of movement of the affected limbs [19]. 4.0 Current Robotic Devices in Ankle Rehabilitation Several robotic devices for rehabilitation of the ankle have been proposed and implemented by researchers. A lot of these devices are used in gait rehabilitation in treadmill training and take the form of ankle-foot orthoses. These devices are worn by the patient primarily to prevent drop foot gait and has either one or two degrees of freedom (dof). The one dof devices allow dorsiflexion and plantarflexion motion. Among the one dof orthoses documented are the adapive ankle-foot orthosis by Blaya and Herr (shown in Figure 2) which uses a series elastic actuator to adaptively vary the ankle impedance. This provides an advantage over passive orthosis in the sense that the ankle impedance is set to a value to prevent drop foot during the swing phase while still allowing the patient to apply force during plantarflexion at toe-off [16]. Another one dof orthosis (Figure 3) reported is produced by Sawicki et al, where a pneumatic muscle actuator is used to assist in powering plantarflexion. The actuator used was able to provide up to 56% of the plantar flexor torque during toe off. The activation of the pneumatic muscle is determined using several methods (footswitch, electromyography signal and push button) [9].

Figure 2: Adaptive Ankle Foot Orthosis by Blaya et al (Reproduced from [16])

Figure 3: Powered ankle foot orthosis by Sawicki et al (Reproduced from [9])

For two dof devices, additional freedom is available for inversion and eversion of the ankle. The ankle robot by Wheeler et al is an example. It has a back-drivable design and is operated using two geared electric motor. Although not powerful enough to permit powered plantarflexion, the device could be used in training of stroke survivors to prevent drop-foot gait [15]. Other two dof devices include the robotic gait trainer by Bharadwaj et al (shown in Figure 4) which consists of a parallel mechanism with two pneumatic spring over muscle (SOM) actuators and that by Agrawal et al which actuates the dorsiflexion-plantarflexion motion while using a spring and damper to passively control the inversion-eversion motion [20].

Figure 4: 2 dof robotic gait trainer by Bharadwaj et al (Reproduced from [20])

Figure 5: The Rutgers Ankle rehabilitation interface (Reproduced from [21])

Robotics devices aimed specifically at rehabilitation of the ankle has also been produced by researchers. The "Rutgers Ankle" as shown in Figure 5 is a haptic device based on the Stewart platform which is designed for rehabilitation of the ankle in a virtual reality setting [7]. It is a full Stewart platform capable of six dof motion and hence is more than sufficient to handle the all possible movements at the ankle [7]. It uses double acting pneumatic actuators, linear position sensors and a six dof force sensor for position and force control of the platform. Position control is used when the therapist wish to govern the exact movement path of the ankle while force control is used for strengthening exercises and zero force ROM exercises [7]. Clinical study in which the device is used for the rehabilitation of post-stroke patients have also shown positive results [14].

Figure 6: The reconfigurable ankle rehabilitation platform by Yoon et al (Reproduced from [12])

A similar pneumatically actuated ankle rehabilitation platform with a parallel structure as shown in Figure 6 was also developed by Yoon et al [12]. This platform however differs from the Rutgers Ankle in the sense that it provides only 4 degrees of freedom, allowing all the movement of the ankle apart from adduction and abduction, the bending motion at the metatarsophalangeal joint (refer to Figure 7) and in addition to that an overall vertical motion. This platform was designed to be reconfigurable to accommodate for the ROM/strengthening exercises in the full 4dof mode while also allowing for a transformation into a wobble board for proprioceptive training. The control strategy used in this device is that of impedance control, with varying impedance settings for different rehabilitation exercises [12]. It is also worth mentioning that Liu et al has also developed an ankle rehabilitation platform that closely resembles that of the Rutgers Ankle but with only 3 dof and is motor driven. With freedom in all three rotational dof, it is able to provide the full range of motion possible at the ankle [13].

Figure 7: Illustration of the metatarsophalangeal joint (Reproduced from [12])

Figure 8: A 3dof ankle rehabilitation platform developed bu Liu et al (Reproduced from [13])

Some commercially available solutions for robotic rehabilitation are supplied by Biodex Medical Systems. One of their products, the Balance System SD, is an electromechanical platform with a touch screen user interface where balance training can take place, offering stabilising, proprioception, ROM and weight shifting exercises [11,22]. Another solution offered by Biodex is the System 3 package which is comprehensive system used for neuromuscular testing and rehabilitation of various joints in the human body. It can be operated in several operating modes to allow for a range of exercises for ROM and strengthening training [11,23].

Figure 9: Balance System SD by Biodex Medical Systems (Reproduced from [22])

Figure 10: System 3 by Biodex Medical Systems (Reproduced from [23])

5.0 Design Issues in Rehabilitation Robotics Existing research has identified several key issues in the area of rehabilitation robotics. One of the main issues is the interaction between machine and patient. While early robotic devices used in rehabilitation are often operated based on position control, recent studies have pointed out that application of pure position control in therapy might not be as effective since the robot is forcing the patient to follow a reference path while the patient remains passive [8]. Also, even if the patients are capable of a certain degree of motion, they will be forced to follow a predefined path which may not be the most optimum for them [8]. Reiner et al has suggested three types of control strategies to allow modification of the reference gait trajectory to better suit the condition of the patient. These are impedance control where the forces applied and the velocity of the robot is governed by a certain impedance relationship, adaptive control where the commanded trajectory is gradually changed from the initial reference value to better suit that "desired" by the patient, and the patient driven motion reinforcement where the device would detect where the patient wish to move his or her limb and provide appropriate assistance based on certain preset gain values [8]. Adaptability of the robotic device is another key feature that should be included in a good rehabilitation robot. This adaptability can be considered in different areas. The first is the adaptability to the change in physical properties of the patient such as size, weight and muscle stiffness. Many orthoses currently being used must be custom made for a particular patient due to their different sizes and joint axis alignments [16,17], an adjustable or adaptable device would therefore allow the same device to be reused. Another form of adaptability that is required is that of the rehabilitation program. It is ideal to have the device automatically alter certain parameters such as resistance when it detects that the patient is gaining in strength over the duration of the exercise. This can provide more challenge for the patient and can potentially speed up the recovery. In order to achieve this, certain indicators must be defined to quantify the progress or ability of the patient and a suitable algorithm must be embedded into the device to tune the exercise parameters. In the work done by Krebs et al for upper limb neuromotor rehabilitation, the time allocated for each movement and the stiffness of the manipulator is varied based on observation of the ability of the patient to reach the target position and their ability to regulate their movement along the desired path over several trials [6]. The performance indicators in this case are derived from measurements being monitored such as the forces applied, by the user, the position and the velocities of the manipulator joints [6].

Other important design issues relevant to rehabilitation robots are safety of the robotic device and the usability of the human-machine interface [3,24]. The former requirement is paramount as rehabilitation robots operate in close proximity of the patient or user as opposed to the case of industrial robots [24]. The safety requirements of rehabilitation robots must therefore be even more stringent to prevent additional injury to the patient and the therapist. It is therefore vital to have several safeguarding measures put in place to stop the operation of the robot once abnormal conditions are encountered. In the ankle robot designed by Wheeler et al, such measures include shutting down the actuator when excessive velocity, acceleration or force is reached, when failure in electronic components has been detected and when the normal movement range is exceeded. On top of that, emergency stop switches are also provided for the user to terminate device operation [15]. In terms of the user interface, more advanced robotic devices such as the MIT-MANUS upper limb rehabilitation robot and the Rutgers Ankle robot have graphical user interfaces to allow the patient to interact with a virtual setting with visual feedback, while also displaying information regarding their performance [6,7]. This will make the exercises more interesting and provide more motivation for patients [7]. From the literature search, it can be seen that a range of robotic devices have been developed for the rehabilitation of the ankle. The positive results shown in clinical trials and the commercial availability of such devices indicates that there is a niche for such systems in the field of rehabilitation. It can be seen that with the exception of the Rutgers Ankle, devices are generally developed to exclusively cater for either the rehabilitation of sprained ankle or for neuromotor rehabilitation. Devices for treatment of sprained ankle all have a fixed base while those designed for motor training takes the form of wearable orthoses to allow their use in locomotion training. In terms of control, it is recognised that a combination of both force and position control is required. Impedance control is often used for ankle rehabilitation robots but other possibilities such as patient driven motion reinforcement are yet to be explored in the reviewed publications. The reviewed ankle rehabilitation devices also appear to lack the adaptability of the MIT-MANUS to allow the evolution of exercise routine as the patient starts to respond to the treatment. In the area of hardware, one of the challenges remaining is the development of compact systems that can provide adequate power for plantarflexion. Another possible area for improvement is the development of devices that can accommodate most patients while minimising or eliminating the number of parts that are specifically fabricated for the patient.

6.0 Objectives of Research Based on a survey of the literature in ankle rehabilitation robotics, this research proposes to develop an intelligent robotic device that can cater for both sprained ankle and lower limb motor rehabilitation. The research objectives are given as follow: A) Design of a parallel robot for use in ankle rehabilitation Due to the advantages of parallel robots over their serial counterpart in terms of load capacity and bandwidth, it is proposed that a wearable ankle rehabilitation device with a parallel kinematic structure to be designed. The larger load capability will allow more torque contribution for powered plantarflexion while the wearable nature of the device will permit its use for both sprained ankle rehabilitation and gait training. It is proposed that a three dof device be produced to allow coverage of all possible motion at the ankle. The tasks associated with this objective will be a detailed investigation into the requirements for ankle rehabilitation to establish design specifications, the study of the human ankle and the optimal design of a parallel mechanism to satisfy the established

specifications. The synthesis of the parallel mechanism is an important part of the design process which requires the kinematic, kinetic and dynamic analysis of the structure to identify available workspace and singularity regions, to find inverse and forward kinematic solutions that is vital for controller development, to understand relationship between task space forces and joint space forces and to obtain a dynamic model for use in simulation and controller design. Actuator selection will also play a major role in design to allow creation of a compact but powerful device, while careful sensor selection would facilitate implementation of control and learning algorithms. B) Development of a method to allow adaptability of device to patient parameters To maximise the utility of the device developed, it must be able to accommodate a wide range of patients with minimal physical modifications. To achieve this, the device must either be insensitive to the dynamic parameters of the patients or have the ability to adapt or learn these parameters. It is clear that the latter option is preferable and this objective will therefore require an investigation into the feasibility of developing a learning algorithm that can identify patient parameters such as size, inertia and stiffness. If this is deemed unfeasible, then a robust design of both the device structure and the controller must be done to minimise the influence of parameter variation on device performance. Otherwise, the learning approach should be pursued. C) Investigation and development of appropriate control strategy for the control of the device Based on the study of the ankle rehabilitation process and the anatomy of the human ankle, an appropriate force and position control strategy must be developed to meet the requirements of the device. This would include the tracking of a predefined trajectory with specified resistance or force limits. It should be kept in mind that different exercises might require a different control scheme. Control strategies such as optimal control, impedance control and patient driven motion reinforcement could be considered. The added challenge here is to develop the controller for a parallel manipulator which is in general a highly non-linear system. As a result, tuning of the controller parameters will most likely require non-linear optimization and appropriate search techniques must be considered to give optimal controller performance. Dynamic modelling of the patient's ankle and leg may also be required to allow improved control performance. A study of the existing position and force controllers is also necessary, with particular attention to on-line adaptation schemes for ensuring that the resultant controller is in line with the previous objective. D) Identification of suitable performance indicators and development of a performance-based adaptive algorithm for ankle rehabilitation To enhance the rate of recovery of the patients, the rehabilitation exercises that they are subjected to can be progressively modified by the robotic device based on certain derived performance indicators to make the exercises more or less challenging depending on the ability of the patient. This objective requires the definition of such performance indicators based on available measurements from the robotic device. An algorithm must then be defined to add intelligence to the robotic device to manage the exercise parameters based on the obtained indicators. One Possible method of achieving this is through the use of fuzzy logic systems which incorporate expert knowledge of the rehabilitation process into the high level control program. 7.0 List of References: 1. M. Hillman (1998) Introduction to the special issue on rehabilitation robotics. Robotica, 16, pp485 2. Dallaway, J. L., Jackson, R. D. and Timmers, P. H. A.(1995) Rehabilitation Robotics in Europe. IEEE Transactions on Rehabilitation Engineering, 3, No. 1, pp35-45 3. Harwin, W.S., Rahman, T. and Foulds, R.A. (1995) A Review of Design Issues in Rehabilitation Robotics with Reference to North American Research. IEEE Transactions on Rehabilitation Engineering, 3, No. 1, pp3-13

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