Home Patient assistive system for the shoulder joint
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Patient assistive system for the shoulder joint

  • Erika Scheuner EMAIL logo , Jonas Fabech , Dominik Textor , Roman Kuster and Bernd Heinlein
Published/Copyright: September 30, 2016
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Current Directions in Biomedical Engineering
From the journal Current Directions in Biomedical Engineering Volume 2 Issue 1

Abstract

The mobility of the upper extremity is essential for everyday activities and for independent living. Shoulder disorders affect the range of motion, therefore a patient assistive system (PAS) for the shoulder joint can be used to compensate the restrictions. The developed PAS supports up to 120° of flexion and abduction. The portable dynamic orthotic consists of two levers and is attached to a hip belt. The upper arm of the patient is connected to the device using a brace. The prototype is driven by one motor and controlled by surface electromyography (EMG). The functionality of the system was successfully verified by tests with healthy subjects. For further development, a study with shoulder patients will be performed and health professionals will evaluate the PAS.

Keywords: activities of daily living (ADL); ambient assisted living (AAL); dynamic orthotic; electromyography (EMG); rehabilitation robotics; shoulder joint

1 Introduction

The mobility of the shoulder joint is important to fulfil activities of daily living (ADL). More than 15% of the population have impaired shoulder joints [1], [2], [3]. An increasing prevalence of shoulder problems has been observed with age. Between 20% and 27% of the elderly are affected by shoulder disorders, mainly due to rotator cuff diseases resulting in pain, lack of mobility or loss of strength [4], [5]. A patient assistive system (PAS) is beneficial for shoulder patients as reduced muscle function and limited range of motion can be compensated. Further fields of applications are post-operative rehabilitation (e.g. after shoulder arthroplasty) and neurorehabilitation of stroke patients.

2 State of the art

Active upper limb systems for rehabilitation purpose or power assist for ADL are being studied for more than 15 years [6]. Early research was based on so called end-effector robots, where the system interfaces with the patient’s arm at only one point, for example the hand. More recently, the research in rehabilitation robotics shifted towards exoskeletons. Exoskeletons are designed to resemble the human anatomy with joint axes matching the anatomical joint axes and operating side by side with the upper limb [7].

Most upper limb exoskeletons were developed for rehabilitation purpose, e.g. to improve motor function in stroke patients [6]. The devices are usually stationary (e.g. CADEN 7 [8], ARMin [9]), so that patients do not have to bear the weight of the exoskeleton. Revised follow-up versions of ARMin are available on the market and in clinical use [10]. Only few systems are portable (e.g. MGA [11], RUPERT IV [12]). To the author’s knowledge, no portable assistive system for the shoulder joint has been commercially realized at the current time.

3 Material and methods

Among the joints in the human body, the shoulder is one of the most complex joints with a large range of motion. The design of a PAS has to take into account the anatomy of the shoulder as well as the required range of motion for the target indication.

3.1 Anatomy of the shoulder

The shoulder joint (Figure 1) connects the humerus, the shoulder girdle consisting of scapula and clavicle with the thorax. The large mobility of the joint is enabled by the physiological scapulathoracic articulation: The scapula can glide over underlying thoracic muscles. The glenohumeral joint between the humeral head and the glenoid of the scapula is mainly stabilized by the rotator cuff muscles. As a consequence, there are almost no bony structures limiting the range of motion of the shoulder joint.

Figure 1: Ventral view of a right shoulder joint with humerus (1), scapula (2), clavicle (3) and three rotator cuff muscles subscapularis (4), infraspinatus (5) and supraspinatus (6).
Figure 1:

Ventral view of a right shoulder joint with humerus (1), scapula (2), clavicle (3) and three rotator cuff muscles subscapularis (4), infraspinatus (5) and supraspinatus (6).

The glenohumeral joint contributes about two thirds and the scapulathoracic joint one third to the abduction range of the arm [13]. The interaction of the glenohumeral und the scapulathoracic joint is called scapulohumeral rhythm [14].

3.2 Required range of motion

In the shoulder joint, the healthy population can reach up to 180° of abduction and flexion when raising the arm against gravity [13]. The required level of abduction and flexion for common ADL according to literature is listed in Table 1.

Table 1:

Required range of abduction and flexion for ADL [15], [16].

ActivityAbductionFlexion
Washing the face0°42°
Combing hair126°113°
Fastening a button at neck level8°28°
Eating with a spoon22°55°
Touching the mouth0°49°
Pouring water into a glass55°56°
Drinking with a glass73°87°
Place can of soup overhead0°121°

Based on the literature research, a functional range of motion of up to 120° of abduction and flexion is considered sufficient for most activities.

3.3 Indication and design requirements

The PAS assists the patient in moving the arm against gravity without replacing the existing muscle forces. It is intended to be used to accomplish housekeeping and everyday activities. In order to successfully cope with ADL, the PAS has to be autonomous portable, whereas a therapy device could be stationary only.

The range of motion of the PAS must be sufficient for ADL. Besides patient specific adaptability ease of use, low weight and an appealing design are essential for the acceptance of a PAS. Finally safety aspects are highly important for a device interacting with the human body.

4 Results

Different approaches can be taken to implement a PAS. In case of an exoskeleton design [17], [18], the rigid links guide the arm and bear the additional forces, thus preventing additional load in the shoulder joint. As an intrinsic requirement of such an exoskeleton, the mechanical joint axes have to be aligned with the anatomical axes of the shoulder joint. Misalignments can lead to harmful constraining forces in the human shoulder joint. In addition, an exoskeleton is bulky and cumbersome to don and doff. For easier adjustment to the patient and to improve the everyday suitability the presented PAS has not been realized as exoskeleton.

4.1 Mechanical system

The resulting prototype with the name PAS Mono (Figure 2) is worn by the patient using a hip belt. The base lever with a length of 390 mm is attached to the belt by a pivoting joint. The rotating lever arm is available in three different lengths of 155, 180 and 205 mm, respectively, according to the height of the patient. The two levers are connected with a hinge joint and the system is optimized to support up to 120° of flexion and abduction, driven by a linear motor with a stroke of 100 mm. The commercially available DC motor offers a maximum dynamic load of 240 N. The upper arm of the patient is strapped by Velcro fastener into a brace. The brace comes in three different sizes and the padding is made of neoprene and can be removed and cleaned.

Figure 2: Components of PAS Mono. (A): Hip belt (1), base lever (2), rotating lever (3), arm brace (4) and belt fixation with battery cage (5). (B): Pivoting joint (I), hinge joints (II-IV) and linear motor (V).
Figure 2:

Components of PAS Mono. (A): Hip belt (1), base lever (2), rotating lever (3), arm brace (4) and belt fixation with battery cage (5). (B): Pivoting joint (I), hinge joints (II-IV) and linear motor (V).

The prototype is constructed in lightweight design. The material of the levers is anodized aluminium and the brace, belt fixation and covering was manufactured by 3D printing in PLA. The system is battery powered and thus completely autonomous and portable at a total weight of only 2.5 kg.

4.2 Control

The PAS Mono can be controlled manually by joy stick or by electromyography (EMG).

In EMG mode (Figure 3), the system detects the activity of the deltoid muscle with surface electrodes. The deltoid was chosen because of its physiological role as the most important muscle to raise the arm. As a consequence, the PAS Mono can be controlled intuitively. If the EMG signal (representing the muscle activity) is above the threshold, the PAS supports the patient in raising the arm. If the signal is below the threshold, the PAS moves downwards. If the signal is within the deadband, the PAS holds its position. The level of the threshold can be adjusted patient specific with a rotary potentiometer. Prior to the comparison with the threshold, the EMG signal is filtered by moving average.

Figure 3: EMG Control of PAS Mono. (A): Surface electrodes (1) with amplifier (2), rotary potentiometer (3) for threshold adjustment and in base lever included control unit (4). (B): EMG signal of deltoid (I), moving average of the EMG signal (II) and muscle activity threshold (III) with deadband (IV).
Figure 3:

EMG Control of PAS Mono. (A): Surface electrodes (1) with amplifier (2), rotary potentiometer (3) for threshold adjustment and in base lever included control unit (4). (B): EMG signal of deltoid (I), moving average of the EMG signal (II) and muscle activity threshold (III) with deadband (IV).

The motor is equipped with hardware end stops and the range of motion of the system can be limited in the software to avoid injury of the patient. The level of assistance can be defined in the software by limiting the supply current of the motor.

4.3 Experiments

The experiments were performed by three healthy subjects, two men and one woman with a mean age of 50.3 ± 6.2 years. Functional tests have shown that the device is adaptable to different persons. The subjects were able to don and doff the PAS Mono independently, using one hand only. The system was controlled intuitively by the deltoid muscle activity. Depending on the subject a learning phase may be needed for precise control.

Several activities have been investigated during the experiments. It turned out that the PAS Mono is particularly helpful if the hand needs to be raised above the head, for example when picking a box or a pot plant from a large shelf (Figure 4). Further tested activities include dusting, watering plants, combing hair, picking a book from a shelf and reading in the book.

Figure 4: Functional tests with healthy subjects at a bookshelf with a total height of 1.89 m. (A): Take a box down. (B): Place a pot plant on top of shelf.
Figure 4:

Functional tests with healthy subjects at a bookshelf with a total height of 1.89 m. (A): Take a box down. (B): Place a pot plant on top of shelf.

5 Discussion

The PAS represents a new kind of device for assistance which may be described best as dynamic shoulder orthotic. The system allows patients to regain functional mobility in the shoulder joint. Thus, the patients can continue an independent lifestyle and remain in their familiar environment. This also helps to reduce the care costs.

The functionality of the PAS Mono was successfully verified by tests with healthy subjects. If a patient has only one impaired shoulder joint, many activities can be accomplished using the healthy side. Lifting objects usually requires both hands and the experiments have shown that the PAS is especially useful in these situations.

Since the motion of the shoulder is not guided as in an exoskeleton, the PAS Mono requires the shoulder joint to be stabilized adequately by the rotator cuff muscles to avoid the risk of luxation. In case of a dysfunction of the deltoid, it would also be possible to use the EMG signal of a different muscle to control the PAS. However, this would imply more training to get accustomed to the device.

Scheduled next, a patient study with shoulder patients will be performed. During functional tasks, the shoulder muscle activities and the compensatory movements of the upper extremities are examined. After the data acquisition, the PAS is presented to the participants of the study and they are questioned about their opinion on the device. In addition to the patient study, health professionals will test and evaluate the PAS Mono. The results of both studies will be used for the further development of the PAS.

Acknowledgement

The authors would like to thank our mechanical technician for manufacturing parts, our students who participated in the project within project theses and the former team members for contributing to the PAS.

Author’s Statement

Research funding: The scientific work was financially supported by the ZHAW Zurich University of Applied Sciences. Conflict of interest: Authors state no conflict of interest. Material and Methods: Informed consent: Informed consent has been obtained from all individuals included in this study. Ethical approval: Tests have been performed with healthy subjects and no health related data were analysed or collected.

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Published Online: 2016-9-30
Published in Print: 2016-9-1

©2016 Erika Scheuner et al., licensee De Gruyter.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

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https://doi.org/10.1515/cdbme-2016-0159
Keywords for this article
activities of daily living (ADL); ambient assisted living (AAL); dynamic orthotic; electromyography (EMG); rehabilitation robotics; shoulder joint
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  43. Classification of morphologic changes in photoplethysmographic waveforms
  44. Novel computation of pulse transit time from multi-channel PPG signals by wavelet transform
  45. Efficient design of FIR filter based low-pass differentiators for biomedical signal processing
  46. Nonlinear causal influences assessed by mutual compression entropy
  47. Comparative study of methods for solving the correspondence problem in EMD applications
  48. fNIRS for future use in auditory diagnostics
  49. Semi-automated detection of fractional shortening in zebrafish embryo heart videos
  50. Blood pressure measurement on the cheek
  51. Derivation of the respiratory rate from directly and indirectly measured respiratory signals using autocorrelation
  52. Left cardiac atrioventricular delay and inter-ventricular delay in cardiac resynchronization therapy responder and non-responder
  53. An automatic systolic peak detector of blood pressure waveforms using 4th order cumulants
  54. Real-time QRS detection using integrated variance for ECG gated cardiac MRI
  55. Preprocessing of unipolar signals acquired by a novel intracardiac mapping system
  56. In-vitro experiments to characterize ventricular electromechanics
  57. Continuous non-invasive monitoring of blood pressure in the operating room: a cuffless optical technology at the fingertip
  58. Application of microwave sensor technology in cardiovascular disease for plaque detection
  59. Artificial blood circulatory and special Ultrasound Doppler probes for detecting and sizing gaseous embolism
  60. Detection of microsleep events in a car driving simulation study using electrocardiographic features
  61. A method to determine the kink resistance of stents and stent delivery systems according to international standards
  62. Comparison of stented bifurcation and straight vessel 3D-simulation with a prior simulated velocity profile inlet
  63. Transient Euler-Lagrange/DEM simulation of stent thrombosis
  64. Automated control of the laser welding process of heart valve scaffolds
  65. Automation of a test bench for accessing the bendability of electrospun vascular grafts
  66. Influence of storage conditions on the release of growth factors in platelet-rich blood derivatives
  67. Cryopreservation of cells using defined serum-free cryoprotective agents
  68. New bioreactor vessel for tissue engineering of human nasal septal chondrocytes
  69. Determination of the membrane hydraulic permeability of MSCs
  70. Climate retainment in carbon dioxide incubators
  71. Multiple factors influencing OR ventilation system effectiveness
  72. Evaluation of an app-based stress protocol
  73. Medication process in Styrian hospitals
  74. Control tower to surgical theater
  75. Development of a skull phantom for the assessment of implant X-ray visibility
  76. Surgical navigation with QR codes
  77. Investigation of the pressure gradient of embolic protection devices
  78. Computer assistance in femoral derotation osteotomy: a bottom-up approach
  79. Automatic depth scanning system for 3D infrared thermography
  80. A service for monitoring the quality of intraoperative cone beam CT images
  81. Resectoscope with an easy to use twist mechanism for improved handling
  82. In vitro simulation of distribution processes following intramuscular injection
  83. Adjusting inkjet printhead parameters to deposit drugs into micro-sized reservoirs
  84. A flexible standalone system with integrated sensor feedback for multi-pad electrode FES of the hand
  85. Smart control for functional electrical stimulation with optimal pulse intensity
  86. Tactile display on the remaining hand for unilateral hand amputees
  87. Effects of sustained electrical stimulation on spasticity assessed by the pendulum test
  88. An improved tracking framework for ultrasound probe localization in image-guided radiosurgery
  89. Improvement of a subviral particle tracker by the use of a LAP-Kalman-algorithm
  90. Learning discriminative classification models for grading anal intraepithelial neoplasia
  91. Regularization of EIT reconstruction based on multi-scales wavelet transforms
  92. Assessing MRI susceptibility artefact through an indicator of image distortion
  93. EyeGuidance – a computer controlled system to guide eye movements
  94. A framework for feedback-based segmentation of 3D image stacks
  95. Doppler optical coherence tomography as a promising tool for detecting fluid in the human middle ear
  96. 3D Local in vivo Environment (LivE) imaging for single cell protein analysis of bone tissue
  97. Inside-Out access strategy using new trans-vascular catheter approach
  98. US/MRI fusion with new optical tracking and marker approach for interventional procedures inside the MRI suite
  99. Impact of different registration methods in MEG source analysis
  100. 3D segmentation of thyroid ultrasound images using active contours
  101. Designing a compact MRI motion phantom
  102. Cerebral cortex classification by conditional random fields applied to intraoperative thermal imaging
  103. Classification of indirect immunofluorescence images using thresholded local binary count features
  104. Analysis of muscle fatigue conditions using time-frequency images and GLCM features
  105. Numerical evaluation of image parameters of ETR-1
  106. Fabrication of a compliant phantom of the human aortic arch for use in Particle Image Velocimetry (PIV) experimentation
  107. Effect of the number of electrodes on the reconstructed lung shape in electrical impedance tomography
  108. Hardware dependencies of GPU-accelerated beamformer performances for microwave breast cancer detection
  109. Computer assisted assessment of progressing osteoradionecrosis of the jaw for clinical diagnosis and treatment
  110. Evaluation of reconstruction parameters of electrical impedance tomography on aorta detection during saline bolus injection
  111. Evaluation of open-source software for the lung segmentation
  112. Automatic determination of lung features of CF patients in CT scans
  113. Image analysis of self-organized multicellular patterns
  114. Effect of key parameters on synthesis of superparamagnetic nanoparticles (SPIONs)
  115. Radiopacity assessment of neurovascular implants
  116. Development of a desiccant based dielectric for monitoring humidity conditions in miniaturized hermetic implantable packages
  117. Development of an artifact-free aneurysm clip
  118. Enhancing the regeneration of bone defects by alkalizing the peri-implant zone – an in vitro approach
  119. Rapid prototyping of replica knee implants for in vitro testing
  120. Protecting ultra- and hyperhydrophilic implant surfaces in dry state from loss of wettability
  121. Advanced wettability analysis of implant surfaces
  122. Patient-specific hip prostheses designed by surgeons
  123. Plasma treatment on novel carbon fiber reinforced PEEK cages to enhance bioactivity
  124. Wear of a total intervertebral disc prosthesis
  125. Digital health and digital biomarkers – enabling value chains on health data
  126. Usability in the lifecycle of medical software development
  127. Influence of different test gases in a non-destructive 100% quality control system for medical devices
  128. Device development guided by user satisfaction survey on auricular vagus nerve stimulation
  129. Empirical assessment of the time course of innovation in biomedical engineering: first results of a comparative approach
  130. Effect of left atrial hypertrophy on P-wave morphology in a computational model
  131. Simulation of intracardiac electrograms around acute ablation lesions
  132. Parametrization of activation based cardiac electrophysiology models using bidomain model simulations
  133. Assessment of nasal resistance using computational fluid dynamics
  134. Resistance in a non-linear autoregressive model of pulmonary mechanics
  135. Inspiratory and expiratory elastance in a non-linear autoregressive model of pulmonary mechanics
  136. Determination of regional lung function in cystic fibrosis using electrical impedance tomography
  137. Development of parietal bone surrogates for parietal graft lift training
  138. Numerical simulation of mechanically stimulated bone remodelling
  139. Conversion of engineering stresses to Cauchy stresses in tensile and compression tests of thermoplastic polymers
  140. Numerical examinations of simplified spondylodesis models concerning energy absorption in magnetic resonance imaging
  141. Principle study on the signal connection at transabdominal fetal pulse oximetry
  142. Influence of Siluron® insertion on model drug distribution in the simulated vitreous body
  143. Evaluating different approaches to identify a three parameter gas exchange model
  144. Effects of fibrosis on the extracellular potential based on 3D reconstructions from histological sections of heart tissue
  145. From imaging to hemodynamics – how reconstruction kernels influence the blood flow predictions in intracranial aneurysms
  146. Flow optimised design of a novel point-of-care diagnostic device for the detection of disease specific biomarkers
  147. Improved FPGA controlled artificial vascular system for plethysmographic measurements
  148. Minimally spaced electrode positions for multi-functional chest sensors: ECG and respiratory signal estimation
  149. Automated detection of alveolar arches for nasoalveolar molding in cleft lip and palate treatment
  150. Control scheme selection in human-machine- interfaces by analysis of activity signals
  151. Event-based sampling for reducing communication load in realtime human motion analysis by wireless inertial sensor networks
  152. Automatic pairing of inertial sensors to lower limb segments – a plug-and-play approach
  153. Contactless respiratory monitoring system for magnetic resonance imaging applications using a laser range sensor
  154. Interactive monitoring system for visual respiratory biofeedback
  155. Development of a low-cost senor based aid for visually impaired people
  156. Patient assistive system for the shoulder joint
  157. A passive beating heart setup for interventional cardiology training
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