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...

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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+task-oriented+training+content+on+skilled+arm-hand+performance+in+stroke:+a+systematic+review.">Influence of task-oriented training content on skilled arm-hand performance in stroke: a systematic review.</a> Neurorehabilitation and Neural Repair. 24 (9), 858-870 (2010).</li><li>Schweighofer, N., Choi, Y., Winstein, C., Gordon, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Task-oriented+rehabilitation+robotics.">Task-oriented rehabilitation robotics.</a> American Journal of Physical Medicine &amp; Rehabilitation. 91, 270-279 (2012).</li><li>Almhdawi, K. A., Mathiowetz, V. G., White, M., delMas, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+occupational+therapy+task-oriented+approach+in+upper+extremity+post-stroke+rehabilitation.">Efficacy of occupational therapy task-oriented approach in upper extremity post-stroke rehabilitation.</a> Occupational Therapy International. 23 (4), 444-456 (2016).</li><li>Takahashi, C. D., Der-Yeghiaian, L., Le, V. H., Cramer, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+robotic+device+for+hand+motor+therapy+after+stroke.">A robotic device for hand motor therapy after stroke.</a> Proceedings of 9th International Conference on Rehabilitation Robotics. , (2005).</li><li>Villafa&#241;e, J. 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J., Thefenne, L., Berton, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bimanual+training+in+stroke:+how+do+coupling+and+symmetry-breaking+matter.">Bimanual training in stroke: how do coupling and symmetry-breaking matter.</a> BMC Neurology. 11, 11 (2011).</li><li>Yue, Z., Zhang, X., Wang, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hand+rehabilitation+robotics+on+poststroke+motor+recovery.">Hand rehabilitation robotics on poststroke motor recovery.</a> Behavioural Neurology. 2017, 1-20 (2017).</li><li>Dovat, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=HandCARE:+a+cable-actuated+rehabilitation+system+to+train+hand+function+after+stroke.">HandCARE: a cable-actuated rehabilitation system to train hand function after stroke.</a> IEEE Transactions on Neural Systems and Rehabilitation Engineering. 16 (6), 582-591 (2008).</li><li>Yoo, C., Park, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+task-oriented+training+on+hand+function+and+activities+of+daily+living+after+stroke.">Impact of task-oriented training on hand function and activities of daily living after stroke.</a> Journal of Physical Therapy Science. 27 (8), 2529-2531 (2015).</li></ol>

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 ...

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