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Review of Exoskeleton Hand Exercisers for

Paralyzed patient

Article · June 2016

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 2nd Research Summit on Computer, Electronics and Electrical Engineering
NIT Arunachal Pradesh 3rd -4th June 2016, pp 35-44

Review of Exoskeleton Hand Exercisers for

Paralyzed patient
Sahadev Roy1, Md Sirajuddin Inamdar1, Subhasis Bhaumik2
1
Dept. of ECE, National Institute of Technology,
2
Dept. Aerospace Engineering and Applied Mechanics, IIEST, Shibpur.

Abstract
Nowadays stroke is the leading cause of disability. Ischemia or haemorrhage in the brain may be counted
among the main reasons of cerebro vascular accident which ultimately results in stroke. In the case of stroke
victims, it is widely accepted that natural recovery accounts for the motor as well as functional restoration
taking place in the first months following the stroke incident. Latest evidence has shown that further
development can be achieved if neural organisation is made to order. Incompletely damaged neural pathways
can be reinstituted with neurons not normally occupied in an activity can be engaged. There has been a lot of
work on power-assisted device therapy and as a result, there is increasingly wide and diverse range of systems.
There are variety of actuation methods and control strategies and they are targeted at different disabilities.
This review explores the art in rehabilitation exoskeletons for the upper arm and hand. Our view regarding
future directions in the area of Rehabilitation Exoskeleton hand.

INTRODUCTION
Rehabilitation Robotics first started in North America. First instances of rehabilitation robots in U.S.
Comprise the floor mounted,4-DOF externally powered exoskeleton developed at Case Institute of
Technology in early 1960’s. Rancho Golden Arm which is a 6-DOF externally power orthosis. In the early
1978 researchers began to explore methods of creating exoskeletons. It progressed from the stuff of science
fiction to nearly commercialized products. While there are many challenges linked with exoskeleton
development. In this paper, we review the history and discuss the state-of-the-art exoskeleton hand. We
provide a design overview of hardware, actuation, sensory, and control systems for most of the devices that
have been included in the literature, and end with an argument about the major advances that have been made
and hurdles yet to be overcome.
The first patent for a mechanical suit appeared in 1980, but exoskeletons, both real and imagined, took off
only recently. Early patents and science fiction research in powered human exoskeleton device started in the
late 1960s, almost in parallel amid a number of research groups in the United States and in the former
Yugoslavia. On the other hand, the former was mainly focused on developing technologies to enhance the
ability of an able-bodied human, often for military purposes, while the latter was targeting on developing
assistive technologies for physically challenged persons.

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Figure 1: Hardiman by General Electric

THE ROLE OF EXOSKELETON HAND EXERCISERS FOR PARALYZED PATIENT

Nowadays stroke is the leading cause of disability. Ischemia or haemorrhage in the brain might be the
reason of cerebro vascular accidents whose end result is stroke (Parker et al., 1986). Fortunately over 75
percent of the patients survive but the majority of them do have residual disabilities with up to one third
suffering from severe disabilities predominantly in the upper limb and hand. Hemiplegia, the most frequent
impairment resulting from stroke, leaves the survivor with a strong unimpaired arm and another weaker
impaired one (hemi paresis). Traumatic injury as well as conditions like muscular dystrophy or arthritis or
regional pain syndrome, also add on as the chief causes of a patient’s disability and functional dependence.
Shortcomings in motor control and coordination synergy patterns, in spasticity and in pain are some of the
most recurrent symptoms of these conditions (Parker et al., 1986). In the case of stroke victims, it is widely
accepted that natural recovery accounts for the motor and functional reinstatement taking place within the
first month after the stroke incident. Recent evidence has shown that further progress can be achieved if
neural organization is customized. Partially damaged neural pathways can be used and neurons not normally
involved in an activity can be occupied.(1) As an example rehabilitation is very much necessary to take care
of flexor tendon injuries or to evade scarring and adhesion following surgery. Rehabilitation is performed
manually by physiotherapists. High personnel costs and lack of motivation of patients to perform exercises
at home is present problem. Some devices help the physiotherapists by applying a uninterrupted passive
motion to the patient’s hand. After hand operations it is necessary to perform rehabilitation to recover
previous dexterity. Socio economic consequences are brutal if the result of rehabilitation is not the best
possible. Another difficulty during the healing process is lack of reproducible measurements. These are
needed to identify restrictions in the dexterity of the hand and to assess the progress of treatment. Successful
impairment identification and constant monitoring of progress are two vital parameters of successful hand
rehabilitation. Physical measurement of hand parameters is time consuming and a task prone to errors.
Sensing gloves could be a prospective tool for increasing the effectiveness and dependability of performing
a rehabilitation task. A review of the most related hand rehabilitation systems that have contributed by
representing a blend of technological advances along with clinical outcomes is presented.

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UPPER ARM REHABILITATION EXOSKELETONS

The most important findings in robot assisted rehabilitation come from two systems that have undergone
rigorous clinical trials: the first system named MIT-MANUS robot (Hogan et al., 1992; Volpe et al., 2000)
and the second one named Palo Alto/VA Stanford MIME (Mirror Image Motion Enabler) (Burgar et al.,
2000). Because of the fact that both systems are using robots rather than using exoskeletons to provide
therapy to stroke patients, they will not be the subject matter of detailed presentation here. The main
conclusion of these clinical trials nonetheless indicated a significant improvement in patient’s motor abilities
although there was no major progress in their functional skills.

THE MOVEMENT ANALYSIS SYSTEM

Figure 2: The first version of the VPL Data Glove Burdea & Coiffet, 1994.

First Data Glove, developed by VPL. This was a thin Lycra glove which measured the finger position by
utilising optic fibres as sensing elements. It utilised two optic fibres per finger in its standard version for the
measurement of flexion as well as extension of the metacarpal along with proximal interphalangeal joints.
The operating principle of data glove was measuring the intensity of light attenuation as light passes all the
way through the optic fibre. The cladding of optic fibre was treated at the position of the measured finger
joint so that its refractive index along with that of the core material allowed attenuation or diminution of light
when the structure was bent. Consequently the flexion of a joint could be measured simply by means of
attenuation of light intensity in the particular optic fibre. The first to incorporate a sensing glove into a
working commercial hand diagnostic system was Greenleaf Medical Systems (Greenleaf, 1992). This system
was called Movement Analysis System. It adapted the fibre optic technology of Data Glove and linked it
with new software that was used to create a tool for quantitative evaluation of upper-extremity function.

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THE ARMIN

Figure 3: ARMin. The image depicts the semi-exoskeleton structure. (Mihelj et.al. 2006)

ARMin is a 6 DOF exoskeleton which was built at the Swiss Federal Institute of Technology based in
Zurich. It is designed specifically as a device-therapy medium for neurological rehabilitation in addition to a
tool to test existing rehabilitation procedures and find the best rehabilitation strategy. In the sense that its
structure can be fixed on the wall by means of an aluminium frame and also the patient’s wheelchair can be
placed underneath ARMin is a semi-exoskeleton solution The exoskeleton has three DOF at the shoulder
allowing horizontal, internal/external and vertical shoulder rotation, one DOF for elbow extension flexion,
one DOF for forearm supination/ pronation and finally, one DOF for flexion/extension of wrist.

WEARABLE ORTHOSIS FOR TREMOR ASSESSMENT AND SUPPRESSION

Figure 4: WOTAS. (A subject wearing the exoskeleton)

WOTAS (Ruiz et al., 2006) is an exoskeleton for the upper limb designed specifically to measure and
compensate for disorders in movement such as tremor. It is done by electric motors at the elbow and the
wrist. The sensory system of WOTAS comprises of chip gyroscopes and kinetic sensors where gyroscopes
are used for measuring tremor force constantly. The total weight of the system is approximately 850grams.
Real-time filtering algorithms and Impedance control strategy is used to distinguish between planned motion
and tremor. WOTAS was found to not affect the subject’s range of motion. At the subsequent stage of the
study, the system added inertia and viscosity in order to suppress tremor (passive control strategy) and was

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capable to measure and estimate tremor parameters. It was projected that the system could suppress
production of 30 percent of the tremor power. The suppression of the tremor power was sustained in the order
of 80 percent in patients with severe tremor.

RECENT TRENDS IN EXOSKELETON HAND

Packages which are application-specific can be connected to the exoskeleton. These packages could
include supplies which are mission-specific, with protective outer coverings having the ability or capable of
operation in extreme weather and threat conditions, having various weapons, electronic systems, or
instrumentation and supplies for medical support and supervision. The exoskeleton can also be used to move
about material in places that are difficult to get to by vehicles or on board ships or also places where forklifts
are not accessible.
Research on hand exoskeletons is still going on. Hand exoskeletons developed for other applications will be
considered as well. Andreas Wege et.al refers to the main applications as haptic interaction along with a
virtual reality or manipulations done remotely with robot arms.(1) Since most of the exoskeleton type master
arm have a similar type kinematics design to that of the slave arm, with actuator controlled by bulky and
heavy electric motors. Sooyong Lee et.al developed force reflecting master arm and master hand using
pneumatic actuators their goal is to make compact and lightweight exoskeleton while providing sufficient
position measurement and force reflection capabilities by reducing degree of freedom. (2) Jamshed Iqbal et.al
proposed Hand EXOskeleton SYStem (HEXOSYS) was driven by multi objective optimization or
improvement strategy and having its inspiration from the human hand. The optimization or improvement
algorithms lead to the choice of most favorable link or connection lengths of the device. The optimization
criterion is based upon isotropy, dexterity and application of perpendicular forces on the finger digits.
Moreover, a series of experiments on the human hand by means of appropriate sensory instrumentation
directed to a range of actuators which lead to a rehabilitation device that is compatible with the human hands
force capabilities. The supply of force on top of position feedback gives the therapist a quantitative feedback
and would mean a more well-organized rehabilitation process.(3) The method used for actuation were planned
so that it would mimic natural motions the maximum amount possible. The ultimate design was thought of
in terms of its combination of movements, controllability along with the placement of components. The
anatomy of the human hand was closely studied. Nara Institute of Science and Technology in regard to the
tactile sensation and manipulation, Jun Ueda et el have projected a grip force control and vision-based slip
margin estimation by its direct feedback the NAIST Hand works as a platform for researches mentioned. This
hand has 4 fingers and every finger has 3 DOF. Its specially designed gear mechanism has all three actuators
that can be embedded in the palm without making use of wire-driven mechanism, i.e. it has relaxed the
restriction on the space for actuators. A tactile fingertip sensor which is vision-based is also presented. It
consists of an embedded small camera, a transparent semi spherical gel, and a force sensor in order to
implement the direct slip margin estimation. It is tricky to raise the spatial resolution since many strain gauges

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must be located within the sensor. To solve the problems mentioned above, a vision-based tactile sensation
and grip-force control method has been proposed. The method proposed has the following advantages a stable
grip force by a direct feedback of the slip margin and a highly accurate sensing by vision-based contact area
measurement. But, in the developed sensor, the camera wasn’t embedded within the sensor. The area in
contact was calculated outside from the fingertip. In this paper, they represent a newly developed fingertip
sensor for the NAIST Hand with normal force raised to the power of 1/3.The normal force about the boundary
is smaller than the normal force in the region of the centre. This results in a slip between the elastic object
and the rigid plate that occurs from the boundary region. Once the entire contact surface slips, the elastic
object begins to slip entirely to the rigid plate, which is called the gross slip.

HAND EXOSKELETON REHABILITATION ROBOT

Figure 5: Pictures of a hand in HEXORR at different postures. (A) The hand flexed. (B) Palm outlook of the hand extended (C) The
hand in extension, with the thumb in pure extension and (D) the hand extended with the thumb in abduction (N Schabowsky et.al 2010)

Christopher N Schabowsky et.al have introduced a recently developed HEXORR (Hand Exoskeleton
Rehabilitation Robot). This device has been designed to offer full range of motion i.e. ROM for all of the
hand’s digits. The thumb actuator permits variable thumb plane of movement to include different degrees of
flexion/extension and adduction/abduction. They developed Compensation algorithms for counteracting
gravity and kinetic friction to develop the exoskeleton’s back drivability. They have also considered a force
assistance or aid mode that provides assistance for extension based on each individual’s requirements. They
did a pilot study on nine unimpaired and five chronic stroke subjects to look into the device’s ability to allow
physiologically precise hand movements throughout the full range of motion. The study also tested the
efficiency of the force assistance mode with the objective of increasing stroke subject’s active full ROM
while still needing active extension torque on the part of the subject. Based on the past subject’s performance
their approach has proven successful in prompting both long-term and short-term motor learning while
reducing error in performance. The adaptive algorithm would use torque and kinematic data from previous
trials to regulate the assistance gain to make best use of extension ROM while it maintains user control by

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requiring active extension torque to finish the actions. (6) Control of the palm arch is important in manipulation
of object and it has been shown that stroke subjects exhibit incomplete and delayed palm arch modulation
throughout a grasping task. Their proposed device currently utilizes a plane support for attaching to the dorsal
face of the hand and doesn’t support palm arch modulation. A possible solution would be to select a pre-
shaped (concave), more flexible material to support the hand that might enable palm arch modulation.
Similarly the inability to adduct/abduct at the MCP joint can be looked upon in future designs by making use
of passive DOFs into the system that permit this motion if the subject is capable.

EXOSKELETON HAND ROBOTIC TRAINING DEVICE

Figure 6: Full set of exoskeleton hand robotic training device (N.S.K. Ho, K.Y. Tong et.al 2011)

N.S.K. Ho, K.Y. Tong et.al (2011) designed an exoskeleton hand robotic guidance or training device for
patients following stroke to vigorously train their impaired hand functions. By measuring surface
electromyography or EMG signals from the impaired hand muscles, this robotic device tries to guess the
stroke patient’s intention and helps in opening or closing of hand. The system consists of embedded controller
and a robotic hand module. The fingers along with the palm of the stroke subject’s hand are placed
comfortably on the robotic hand module by means of Velcro straps and finger rings. The DIP joint and palm
area of the hand in figure 6 are left open to let user to grip the objects as well as feel it with their own fingers.
Every hand module consists of 5 finger assemblies and also a platform for palm support. Every finger
assembly will be actuated by a one linear actuator (Firgelli L12) and it provides two DOF for every finger at
the PIP and MCP jointly by the mechanical linkage system. Proximal section rotates round the virtual centre
placed at the PIP (proximal inter phalangeal) joint while the distal section moves around the virtual centre
situated at the MCP (metacarpophalangeal) joint from totally extended position to totally flexed position, the
finger assembly provides sixty five degrees and fifty five degrees ROM (range of motion) for the PIP and
MCP joints respectively. When under no load, the highest contraction speed of the robotic hand is just about
two seconds to fully close or open the robotic hand. (7)

Controller Section of Exoskeleton Hand:

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Controller Section is the heart of Exoskeleton Hand. Andreas Wege and Günter Hommel in 2005
demonstrated the Real-Time controller. The control system (figure 7) can be divided in 3 parts: the host
computer running the interface for the instructor, a real-time controller, and the interface for client giving
visual feedback to the user. The instructor interface and the user can run on different computers if desired.
The network interfaces are connected through different parts of the system. The RTC (Real-Time Controller)
from NI (National Instruments) is running the RTOS (real-time operati ng system) Pharlap and samples
all data from sensor (quadrature encoders, hall sensors, force sensors and motor currents) using data
acquisition cards.

Figure 7: Control system. (Andreas Wege and Günter Hommel 2005)

All the control cycles are executed on this controller as well. The motors are driven through output
channels that are analog in nature which in turn are linked to PWM-controllers. Calculation power, number
of analog inputs, encoder inputs, and analog outputs are designed for the control of the complete hand
exoskeleton with 20 axes. A control frequency for PID controllers of at least 1 KHz will be possible. The
control system and interfaces were developed using LabVIEW from National Instruments. The computer host
running the interface for the instructor displays all sensor data and also allows the setting of desired motion.
The system even allows the recording of motion for all joints. The motion can be filtered and replayed later
at a customised speed. The computer does not have to be at the same location as the rest of the system. The
application can be run on any personal computer connected to the internet. Several control loops (PID) run
separately for every controlled joint. The control variable of each control loop is the angle measured at the
quadrature encoders of the motors. The PID parameters of the control loops were tuned for a stable motion.
Less precision in the position control is better than undesired overshoots or oscillations. (8) Gunter Hommel
and Sheng Huanye in 2006 developed an embedded system to control Exoskeleton Hand. The block diagram
developed by them is shown in figure 8.Real time controller control 20 joints.

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Figure 8: The block diagram of Exoskeleton hand (Gunter Hommel and Sheng Huanye 2006)

The Exoskeleton structure rests on the hand’s dorsal side and the forces are applied in that direction. The
feedback force is obtained by dc motors placed on a low profile power pack and are transmitted to the fingers
by low friction pull-cables. The finger flexion measurement is achieved by an arrangement of flexible
resistive sensors incorporated in a soft lycra glove and custom made hear electromagnetic sensors embedded
in the exoskeleton's metallic structure. The system is designed such that it allows integration of Hall effect
sensors for precise measurement of abduction and adduction angles of the fingers.(9)Researchers are planning
to add many features like the device always monitoring the improvement of patient. It storing the current
data like force produced whilst pinching action takes place, fingertip force etc for future reference. This data
can also help the doctor to know about the current status and trends of improvements of patients.

CONCLUSION

Exoskeleton hand exerciser is a prosthetics device for paralyzed patients who have lost their control over
hand. The device can be easily attached to the real hands. So in order to improve the therapy results and also
to reduce the cost of rehabilitation an exoskeleton hand definitely helps people. However new devices are
required to improve the existing designs. These simple mechatronics device may be all that is needed to offer
different types of exercise required for a patient. The exoskeletons use new self-aligning axes, reducing setup
times and potentially painful interaction forces. It can be used as new compliant but powerful light weight
actuators, which are useful for both stroke therapy and impairment quantification. The device always
monitors improvement of patient, while it also stores the current data like force produced during pinching
action, fingertip force etc for future reference. These data also help the doctor in identifying the current status
of patient and also gives a track record of the patient’s improvement. The exoskeleton hand also helps the
paralyzed patient to do basic tasks without external help. The development of human hand exoskeletons and
robotic hands for industrial and medical applications is a very promising area having huge potential. With
development in technology, the power of actuators and decreased size of electrical components, the
possibility of creating very complex robotic structures in small spaces is ever increasing. However as the
human hand remains the most mechanically complex and dynamic part of the human body, replicating its

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every function is incredibly difficult. Research is going on to clearly define the difficulty of creating a
dynamic control system responsible for replicating the human hands movement characteristics and the actual
construction of a hand exoskeleton.
In order to successfully replicate the human hand for an exoskeleton application both physical and
electronic design factors must be pushed to the limit. The accomplished design must integrate very precise
physical characteristics, as well as seamless electronic integration and supporting apparatus. However, in
order to further develop the human exoskeleton concept the mechanical and electronic control of the human
hands must be reproduced, and until this time exoskeletons will remain in their early stage of development.

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