Name: development of a novel task-oriented rehabilitation program using a bimanual exoskeleton robotic hand
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This project was supported by Chang Gung Medical Foundation with grant BMRP390021 and the Ministry of Science and Technology with grants MOST 107-2218-E-182A-001 and 108-2218-E-182A-001.

The training protocol and informed consent document were reviewed and approved by the Institutional Review Board of the Chang Gung Medical Foundation. The details of the study and the procedures were clearly explained to each subject.
1. Recruitment of three healthy adults
<ol>
	<li>Perform the screening process using the following inclusion criteria: (1) age 20&#8211;60 years, (2) already signed informed consent, (3) normal function in upper limbs, (4) Mini-Mental State Examination (MMSE) s...

<ol>
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The results of this study showed the following: (1) both groups could successfully grasp the objects provided with the robotic hand system. They were able to complete this task with a nearly 100% success rate, which verifies the feasibility of the proposed robot-assisted task-oriented training program. (2) There were no reports of injury or adverse events during the study period and all patients reported that the robotic hand system was helpful to manipulate objects. This confirmed the acceptability of the robotic hand s...

Most (80%) stroke patients experience a deficit in the hand and have difficulty in independently performing manual tasks that are pertinent to daily living1. However, the complex nature of manual tasks means that it is a significant challenge to design a task-oriented training program for hand rehabilitation2. In recent years, many robotic devices have been developed for hand rehabilitation3,4, but few training protocols assisted by robotic devices allow a patient to interact with real objects. It is unclear exactly how a task-oriented training program for hand function rehabilitation can be applied using robotic devices for patients who experience hand dysfunction due to stroke.
Task-oriented training is used to improve hand function5,6 and is commonly applied in the rehabilitation for upper limb dysfunction due to stroke. It is used to increase neuroplasticity and is highly dependent on individual neurological deficits and functional demands7. However, during task-oriented training, patients experience difficultly in manipulating objects if hand function is impaired. Examples of this include poor grasp or limited pinch functions. Therapists also show difficulty in guiding patients&#8217; finger movements individually, which therefore limits the variation of grasping tasks. Robotic devices are thus necessary to increase the effectiveness of task-oriented training by explicitly guiding hand movement during repetitive training2,8.
Previous studies only used rehabilitation robots for task-oriented training on upper-limb reaching tasks3. It is unclear how robot-assisted rehabilitation can be employed for task-oriented training targeting at hand function. An exoskeleton&#160;hand, HWARD, has been used to guide the fingers to grasp and release objects8. However, this device does not allow varied grasping patterns because it lacks the necessary degrees of freedom. Recently, other devices that target moving a patient&#8217;s fingers individually have been developed9. However, these devices have not previously been used for neurorehabilitation. The robotic devices mentioned above are all unilateral robots. In contrast, the robotic hand system presented here needs the cooperation of unaffected and affected hands. The robotic hand system is specifically designed for rehabilitation purposes using the master&#8211;slave mechanism to achieve symmetric bimanual hand movements. The system consists of an exoskeleton hand (worn on the affected hand), a control box, and a sensory glove (worn on the unaffected hand). Each finger module of the exoskeleton hand is driven by a motor with one degree of freedom and its joints are linked using a mechanical linkage system. Two sizes, S and M, are designed to fit different subjects. The control box provides two therapeutic modes, the passive range of motion (PROM) and mirror-guided motion modes, through which the patient&#8217;s affected hand can be manipulated by the exoskeleton hand. In the PROM mode, the control box sends input commands to the exoskeleton while moves the subject&#8217;s hand to perform full finger flexion/extension. It contains two modes: single-finger mode (acts in sequence from thumb to little finger) and five fingers mode (five fingers move together). In the mirror-guided motion mode, the master (sensor glove)&#8211;slave (exoskeleton hand) mechanism is implemented, in which the movement of each finger is detected by the sensor glove and signals of the joint angles are transmitted to the control box to manipulate the exoskeleton hand.
When equipped the robotic hand system, the subjects were instructed to move their affected hands under the guidance of the exoskeleton hand controlled by unaffected hands which is bimanual movement training (BMT)10. According to previous research, BMT is able to activate similar neural pathways in both hemispheres of the brain and prevent the trans-hemisphere inhibition that hinders the recovery of neuronal function in the lesion hemisphere10. Brunner et al.11 compared BMT to constraint-induced movement therapy (CIMT) in sub-acute stroke patients. They suggested that BMT tends to activate more neural networks in both hemispheres than CIMT, and there was no significant difference in improvement of hand function between the BMT and CIMT approaches. Sleimen-Malkoun et al.12 also suggested that through BMT, stroke patients are able to re-establish both paretic limb control and bimanual control. That is to say, training should comprise bimanual tasks that focus on using the affected arm. Moreover, the coordination of both hands is necessary for activities of daily living (ADL)11,12. Therefore, it is crucial to develop a bimanual robot-assisted task-oriented training program for post-stroke patients and objects that can be grasped or pinched by patients wearing the robotic hand system.
In this study, a variety of grasping objects were designed based on the needs of occupational therapy and the mechanical properties of rehabilitation robots. A task-oriented training protocol was developed using robotic rehabilitation devices for patients with distal upper limb dysfunction due to stroke. The purpose of this study was to investigate the feasibility, and acceptability of the task-oriented training program using an exoskeleton robot and newly designed grasping objects.

<table>
	<tbody>
		<tr>
			<td>Control Box</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HB01</td>
			<td>The control box includes a power supply, sensor glove signal receiver, motor signal transmitter, and exoskeletal hand motion mode selection unit.</td>
		</tr>
		<tr>
			<td>Exoskeletal Hand</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HS01</td>
			<td>It is a wearable device causing the patient&#39;s fingers to move and is driven by an external motor and mechanical assembly.</td>
		</tr>
		<tr>
			<td>Sensor Glove</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HM01</td>
			<td>Worn on the patient&#39;s unaffected side hand. The sensors in the sensor glove will detect flexing and extension of the hand, and this data will be used to control the exoskeletal hand when in bimanual mode.</td>
		</tr>
	</tbody>
</table>

development of a novel task-oriented rehabilitation program using a bimanual exoskeleton robotic hand

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor control. However, it is unclear how conventional occupational training strategies can be applied to the use of rehabilitation robots. Novel robotic technologies and occupational therapy concepts are used to develop a protocol that allows patients with impaired upper limb function to grasp objects using their affected hand through a variety of pinching and grasping functions. To conduct this appropriately, we used five types of objects: a peg, a rectangular cube, a cube, a ball, and a cylindrical bar. We also equipped the patients with a robotic hand, the Mirror Hand, an exoskeleton&#160;hand that is fitted to the subject&#8217;s affected hand and follows the movement of the sensor glove fitted to their unaffected hand (bimanual movement training (BMT)). This study had two stages. Three healthy subjects were first recruited to test the feasibility and acceptability of the training program. Three patients with hand dysfunction caused by stroke were then recruited to confirm the feasibility and acceptability of the training program, which was conducted on 3 consecutive days. On each day, the patient was monitored during 5 min of movement in a passive range of motion, 5 min of robot-assisted bimanual movement, and task-oriented training using the five objects. The results showed that both healthy subjects and subjects who had suffered a stroke in conjunction with the robotic hand could successfully grasp the objects. Both healthy subjects and those who had suffered a stroke performed well with the robot-assisted task-oriented training program in terms of feasibility and acceptability.

A total of six subjects were enrolled in this study, including three healthy subjects and three post-stroke subjects. The demographic data of both groups are shown in Supplementary Table 1. The average age of the healthy group was 28 (range: 24&#8211;30), whereas the average age of the patient group was 49 (40&#8211;57). The average assessment scores of the patient group were as follows: (1) MMSE=27 (26&#8211;29), (2) FMA=11.3 (6&#8211;15), (3) MAS=1, (4) Brunnstrom stage=2.
I...

Watch this Scientific Journal Video about Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand at JoVE.com

Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand

This study reports the development of a novel robot-assisted task-oriented program for hand rehabilitation. The developmental process consists of experiments using both healthy subjects and subjects who have had a stroke and suffered from subsequent motor control dysfunction.

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor ...

This robot-assisted, task-oriented training protocol was developed for patients with hand dysfunction caused by neurological deficits. Our protocol is the first to integrate task-oriented training program with a robotic hand for hand function rehabilitation and the first to investigate the feasibility and the acceptability of the protocol. We have designed specialized objects that can be manipulated using the training protocol.Then our robotic hand system can be applied to bimanual movement training. Demonstrating the procedure will be Yi-Mei Chen and Szu-Shen Lai, occupational therapists from my department. Before beginning the analysis, place the sensor on the subject's unaffected hand, and use the hook-and-loop tape to secure the wrist.Use a clean pad to wrap the affected hand, and securely fasten the hook-and-loop tape. Loosen the thumb mechanism of the exoskeleton hand to allow adjustment of the thumb-opening angle, and place the affected hand in the exoskeleton hand. Fasten the hook and loop to the palm through the fastening ring.After that, fasten the fingers one by one, beginning with the forefinger and finishing with the thumb. Fasten the hook-and-loop tape parallel to the wrist through the fastening ring, and adjust the thumb to a comfortable angle. Then, tighten the thumb mechanism.To set up the control box, insert the cable for the exoskeleton hand and insert the cable for the sensor glove. Insert both sets of cables into the socket in the control box, and insert the power cable into the control box. Then, connect the power cable to an outlet with the correct voltage.When the system and subject are ready, switch to the control box, and set the mode to Five Fingers to allow the exoskeleton hand to move the subject's fingers passively. Ask the subject to perform a grasp-and-release task guided by the exoskeleton hand for 2.5 minutes. Switch the mode to Single Finger.Then, let the exoskeleton hand move the subject's fingers individually and passively while the subject extends and retracts individual fingers for 2.5 minutes. For a robot-assisted bimanual movement session, switch the mode to Mirror to allow the movement of the unaffected hand wearing the sensor glove to control the exoskeleton hand movements. To conduct a trial of the subject's ability to manipulate objects using the robotic hand system, fit the exoskeleton hand to the subject's unaffected hand and the sensor glove to the unaffected hand as just demonstrated, and place a sling under the subject's elbow and exoskeleton hand to support the affected arm.Next, conduct a warm-up session as just demonstrated. After the warm-up, use the robotic hand system for five minutes to demonstrate how to manipulate the designed objects, including using palmar prehension to pick up the peg, a lateral prehension to pick up the rectangular cube, a three-point chuck to pick up the cube, a spherical grasp to pick up the ball, and a cylindrical grasp to pick up the cylindrical bar. After the demonstration, place two bases bilaterally in front of the subject's hands, and place the objects onto the top of one base to assist in their manipulation.Have the subject use the robotic hand system to grasp each object 20 times a day for three consecutive days, starting at the area of the base and lifting, moving, and releasing each object onto the midline while monitoring and recording the success rate for each attempt. In this representative analysis, three healthy subjects and three post-stroke subjects were assessed. The average age of the healthy group was 28, whereas the average age of the patient group was 49.Mini-Mental State Examination, Fugl-Meyer Assessment, Modified Ashworth Scale finger, and Brunnstrom stage scores were also obtained for each patient. The subjects in the healthy group perfectly manipulated all of the objects with and without the robotic hand system, with an average success rate of 100%for every task. All of the patients, however, exhibited difficulties in manipulating the objects without the robotic hand system, demonstrating a 0%success rate for all of the objects.In contrast, all of the patient success rates increased significantly when the robotic hand system was used, approaching rates similar to those observed in healthy subjects, supporting the feasibility of using the robotic hand system in stroke patients. Remind the subjects to concentrate on the movement control of their bilateral hands during bimanual movement training, making sure that the grasp patterns on the objects are correct. Following this procedure, a randomized controlled trial is required to determine the therapeutic effects of the training protocol.Using this technique, researchers can program rehabilitation protocols with delicate finger movement for severe hand dysfunction and can explore the effects on brain neuroplasticity and functional outcomes.

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