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B } is the
desired damping matrix, and X
m
is the measured platform position. The desired stiffness,
damping matrices, and foot position X
d
should be selected (explained later). The position
adjustment vector X
imp
can be computed by following relations
imp
imp m
X B KX F
&
+ = (3)
where F
m
is the measured interaction force that is estimated by pressure sensors. The desired
set point position command X
c
and the position adjustment vector X
imp
are related by
imp d c
X X X = (4)
Thus, the position command X
c
is modified by the position adjustment vector X
imp
calculated
from the target impedance relationship in equation (3) with the measured force F
m
. If the
position control of the robot is perfectly operating (X
c
= X
m
), the desirable force F
d
in equation
11
(2) become ideally equal to the measured force F
m
in equation (3), which means that the
desired impedance have been achieved ideally. Note that if there are no interaction forces, the
desired foot position X
d
becomes the desired position command X
c
and the impedance control
is operating as only a position control. Also, the larger impedance implies the harder movement
and the smaller impedance implies the easier movement of the platform through the foot.
3.1.2. Inner loop (position control loop)
The position control loop should be designed to operate as ideally as possible to achieve
desirable impedance more closely. The position control is implemented with feedback control
of PD type with feedforward control input.
10
If the desired command input X
c
is given, the
resultant measured platform coordinates X
m
can be obtained from the measured actuator
lengths by forward kinematics (FK). The position control input will be transformed into the
desired actuator input L
c
after being mapped through inverse kinematics (IK).
Then, the independent joint control will be applied to actuator, which is controlled by the
four-way proportional valve (Enfield Technology). The control input of the double acting
pneumatic cylinder with special low-friction type (Bimba Corp.) is proportional to differential
pressure. The generated differential pressure is expressed as
) ( ) )( / (
u l m m c i d p
P P K L L s K s K K P + + = (5)
where L
c
and L
m
are the commanded and measured cylinder displacements, K
p
, K
d
, and K
i
are
proportional, derivative, integral gains, P
l
and P
u
are lower and upper pressures of the cylinder
chamber, respectively, and K
m
is the pressure feedback gain. The pressure feedback is
proportional to the external force applied to the piston. The system stability can be improved
by augmenting differential pressure feedback to a position controller.
31
We define instability
as the situation in which vibration occurs while maintaining a fixed pose (i.e. at constant X
d
)
during foot interaction with the robot. The pressure sensor can directly detect the forces such
as friction or external disturbances, and can efficiently reject force disturbances that are
12
generated by patients legs during trials. The PID scheme with pressure feedback gives
comparable results with other robust controllers.
32
3.2. Achievable Impedance
For the suggested impedance controller, the maximum stiffness
33-34
, the ability to create
force in response to a disturbance, can be obtained by measuring the changed positions from
home position and the resultant forces of the device with the largest possible position gain
while not inducing control instabilities. Similarly, the minimum DC stiffness can be achieved
by measuring the changed positions and the resultant forces. In the case of position control
with pressure differential feedback, the achievable stiffness range was increased about 20%,
which shows the importance of the position controller performance for wider impedance range.
When the minimum achievable impedance experiments are performed at the position
controller with and without pressured feedback, Fig. 11 shows that the platform driven by
position controller without differential pressure feedback becomes unstable at a stiffness gain
of
r z
K =10kN/m, whereas the platform driven by position controller with differential pressure
feedback is stable at the same stiffness gain. The minimum achievable stiffness with pressured
feedback was stable until 7kN/m without causing instability. Since damping coefficient is not
utilized for implementation of each exercise of ankle rehabilitation stages in the later section,
this coefficient is set to zero. When the position controller is set to its maximum and minimum
stable gains, the achievable maximum and minimum stiffness were measured (Table II).
4. IMPEDANCE DESIGN FOR EACH EXERCISE MODE
Parameters of the position-based impedance control such as the desirable foot position X
d
,
the desirable foot velocity X
d
, and the desired impedance are designed for each exercise mode.
13
4.1. Range of Motion Exercise
There are three types of ROM exercises: passive, active-assist, and active. Passive ROM
(PROM) is the movement that is applied to a joint only by efforts such as another persons or a
machine while the patient does not resist against the motion. To realize PROM, a fine position
control should be guaranteed to keep the range of motion within acceptable range without
inducing any pain even though some external force is exerted. This demands implication of
infinite impedance Z
inf
. By setting the desired impedance infinite, the position can be
controlled through the impedance controller. This reduces X
imp
to become zero. Since the
resultant impedance generated by setting of the desirable impedance of the robot cannot exceed
the maximum achievable impedance, the desirable impedance was set to the maximum
achievable impedance. Active assist range of motion (AAROM) represents a joint movement
that needs partial assistance from an external force. Active range of motion (AROM) is the
movement of a joint that is provided totally by the patient without external assistance. Thus, the
amount of selected impedance determines the effect of assistance suggesting minimum and
maximum achievable range of the specific device. In PROM and AAROM mode, a desired
staircase position command X
d
can be designated by a physical therapist who can directly
diagnose the patients conditions during testing as well as operations, keeping in view of static
movements. The staircase command input may be more convenient to generate necessary
change of the patients current ROM with respect to the patients direct response.
4.2. Strengthening Exercise
Strengthening exercises enhance muscle strength by generating more strain on a muscle than
it is in normal condition. Strengthening exercises can be classified into the form of isometric,
isotonic and isokinetic strengthening.
4.2.1. Isometric exercise
Strengthening can be applied to the proper joint angle with exact isolation about the region of
14
weak muscles. Isometric training is efficient to develop overall strength of particular muscles.
Even though muscles contract, there is no movement in the affected joints during isometric
exercises. To satisfy this mode, the infinite impedance Z
inf
should be applied keeping position
command.
4.2.2. Isotonic exercise
Isotonic exercise is a dynamic form of exercise that is carried out against a constant or
variable load through the available ROM. Isotonic exercise is different from isometric exercise
in that there is movement of a joint during the exercise. Weight training with dumbbells and
barbells, or heel raise are standard examples of an isotonic exercise. The muscle can be
shortened or lengthened with a constant weight throughout the range of motion. The isotonic
controller is implemented when the human moves the foot, while the desired force/torque is
maintained constant. By using (5) with B=0, the desired foot position X
d
can be represented by
m d d
X K F X + = / (6)
Then, the desired position control command
c
X can be represented by
m m d m m d imp d c
X K F F K F X K F X X X + = + = = / ) ( / / (7)
Eq. (7) implies that X
c
will be changed to keep the measured force F
m
to desired force F
d
.
4.2.3. Isokinetic exercise
Isokinetic exercise allows constant preset speed with variable resistance as the muscle moves
through full ROM. This exercise can provide maximal loading throughout. Despite how hard
and fast the patient works, the isokinetic properties of the robot should permit patients to move
only as fast as preset speed. To satisfy isokinetic motions, the desired velocity command
d
X
&
should be preset. In addition, the infinite impedance Z
inf
should be applied to generate
velocity control, which should prevent the robot from deviating from the desired speed by
external disturbances like patients muscle force. Since the impedance controller with the
infinite impedance Z
inf
behaves a position controller, the desirable foot position X
d
can be
15
represented by the desirable foot velocity
d
X
&
and time t
X
d
= X
0
+
d
X
&
t (8)
Where X
0
is the initial foot position. The desirable foot velocity
d
X
&
should be constant in
piecewise periods to provide isokinetic mode.
4.3. Proprioception Exercise
The loss of proprioception will cause a patient not to recognize his joint motions, while people
with a strong proprioceptive sense can have good balance and coordination. A common
progression when performing balance exercise is to move from a position of non-weight
bearing to weight bearing, bilateral stance to unilateral stance, eyes open to eyes closed, firm
surface to soft, uneven or moving surface.
3
For static balancing exercise, motions similar to
wobble board are required to be generated by impedance control. The wobble board allows
only rotational motions of pitch, roll, and yaw about a hemispherical pivot at the center of
lower side. In order to mimic the wobble board motions, the impedance of translational
motions should be maximized to fix the platform at a constant position, while the impedance of
the orientation motions should be minimized to give free orientation motions at platform center.
Then, the dynamic balancing exercises are performed to improve effectiveness. Dynamic
balancing can be implemented by varying the desired positions and changing the desired
impedance of the platform. Table III summarizes the design parameters of impedance Z,
desired position and velocity command, and the desirable exercise examples with respect to
each exercise mode.
5. EXPERIMENTS OF EXERCISE MODES
For experiments, the total ankle rehabilitation system is suggested for patient to perform each
exercise mode with visual feedback, which composed of the robotic device, the controller with
pneumatic actuators, the host PC, and a patient. The host PC displays virtual environments and
16
connects the controller through RS232C serial communication. The rotation and torque
information of the robotic platform will be transferred to the virtual environments and will be
stored for the patients histories at DB. The suggested system is shown in Fig. 12. In this
section, the experiment results of each exercise mode that is designed based on impedance
parameters will be shown.
5.1. ROM Exercises
Based on the patients condition, initial commands utilizing stair type exercise scenario are set.
Fig. 13 shows rotation and torque of the inversion (negative roll motion of the platform) in the
AAROM and PROM modes. For AAROM mode, desired stair input was displayed at
computer monitor for visual feedback of a patient. Fig. 13(a) shows the desired and measured
stair response for each ROM mode. PROM mode with infinite impedance setting follows the
desired trajectory well, while AAROM mode with
K =150Nm/rad and
B =0 has bigger
trajectory errors due to the lower impedance setting. Fig. 13(b) shows the measured torque for
each case. The relatively small measured torque value at AAROM means that the subject
applied his own torque in order to follow the desired trajectory. Conversely, the PROM mode
needs larger torque because of inactive efforts from the subject.
5.2. Strengthening Exercise
5.2.1. Isometric exercise
For isometric exercise, virtual environments have been developed in the previous research
for ankle and hand rehabilitation.
35-36
Fig. 14 shows the image viewers that are used to give
motivation for isometric exercise. There are two images for which the front image will be
widened proportional to the torque exerted by a patient. If the device driven by human foot
exceeds beyond threshold (torque) selected by a therapist, the hidden image will appear at the
front. Then, another mage will be positioned on the back. The torques of the inversion and
17
eversion directions will divide the front image into horizontal direction, while the torques of
the dorsiflexion and plantar flexion directions will divide the hidden image into horizontal
direction. Fig. 15 shows that even though the position variations are relatively small (within 2
degrees), which is required to be kept constant for isometric exercises, the exerted maximum
torques about inversion and eversion increases or decreases according to a patients efforts at
the ankle joint. If the exerted torque is higher than the present threshold (e.g. 50Nm), the next
scene will appear in the front. The torque threshold is determined by physical therapists
considering the patients conditions.
5.2.2. Heel raise for isotonic excise
Heel raise motion is a standard isotonic exercise since there is constant torque to ankle axis
due to a human weight. This exercise can be generated by setting the desired position control
command X
c
at equation (7) with desired force and stiffness. In order to generate heel raise
motion, the only pitch motion
r
of the rear platform should be moved, while the pitch motion
f
of the front platform and roll motion should be zero since toe attached to the front platform is
steady. Fig. 16 shows that even though the pitch motion
r
(platar flexion or dorsiflexion) is
changing, the device can keep the measured torque constant; 25Nm with small oscillations,
where
r
K
=500Nm/rad,
r
B
=0, and X
d
(
r
)=0.5 rad (28.65).
5.2.3. Gait trajectories training for isokinetic exercise
The ankle and foot motions during walking at the ground level is generated based on normal
gait.
37
The task specific and repetitive gait training of a patient at foot and ankle can increase
the strength of the lower limbs with an isokinetic exercise. Since the mechanisms for the
unrolling foot during stance phase could generate the development of ankle sprains, Willems et.
al
38
suggested that effective prevention and rehabilitation of inversion sprains should include
attention to gait patterns and adjustments of foot biomechanics in subjects at risk of a sprain.
Therefore, the test of ankle and foot motions about the repetitive normal gait trajectories was
18
executed while the subject was sitting on the chair.
When the heel-striking angle, heel-off angle, and toe-off angle are 30, respectively, the foot
trajectory configurations at planar surface with respect to gait cycle are illustrated in Fig. 17.
Fig.18 (a) shows the desired and measured rotation value of pitch angles
r
of the real platform
in order to generate desirable trajectories with respect to gait cycle. Fig. 18(b) shows the
desired and measured angular velocity
r
&
of the rear platform. At piecewise periods, the
angular velocities of the rear platform generated constant values, a desirable characteristic for
isokinetic exercises. Through experiments, the ioskinetic motions were well generated
regardless of subjects intentions. These kinds of advanced functional training including MTP
joint motions will not be possible by using Cybex and Biodex, which may be helpful to
increase the coordination of the lower limbs during real walking.
5.3. Proprioception/Balance Exercise
A ball stabilization game may be used for these exercises (See Fig. 19). By standing on the
large plate and shifting his/her weight from left to right or from fore to rear, the patient can
make the board tilt about the two ankle axes. The balance by maintaining center of gravity
within bodys base of support and the coordination by moving patients two limbs can be
improved simultaneously. Fig. 20 shows experimental results for the condition that a subject
was standing on the platform with double legs and shifted his center of gravity from fore to rear
while keeping his bodys positions stable. The impedance values are set to
r
z
K =80kN/m for
hard surface,
r
K
=0.2kNm/rad, and
r
K
(pitch axis)
Figure 7. Maximum torques of the two axes for strengthening exercises
Figure 8. The maximum z-axis forces at center of the rear platform for balancing exercises
(a) ROM/ strengthening type (b) Balance/proprioception type
Figure 9. Ankle rehabilitation device
27
Figure 10. Impedance control block diagram for rehabilitation exercises
(a) position (b) force
Figure 11. Minimum achievable stiffness at
r
z
K =10kN/m
Figure 12. Total Ankle Rehabilitation System
28
(a) X
m
( axis) (b) F
m
( axis)
Figure 13. AAROM and PROM for inversion
Figure 14. Image viewer window
35
a) X
m
( axis) b) F
m
( axis)
Figure 15. Isometric exercise for inversion and eversion
29
(a) X
m
(
r
axis) (b) F
m
(
r
axis)
Figure 16. Isotonic exercise at heel raise
(a) Heel-strike (0%) (b) Foot-flat (10%) (c) Heel-off (50%)
(d) Toe-off (60%) (e) Initial swing (70%) (f) Terminal swing (90%)
Figure 17. The mechanism configuration according to gait cycle at ground level
30
(a) measured angles
r
(b) measured angular velocity (
r
&
)
Fig. 18. The walking motions for isokinetic exercise
Figure 19. Ball Stabilization Virtual Environment
(a) F
m
(Z
r
axis) (b) X
m
(Z
r
axis)
31
(c) F
m
(
r
and axes) (d) X
m
(
r
and axes)
Figure 20. Balance /coordination exercise results
TABLE I
REQUIREMENTS OF ANKLE JOINT AND DESIGNED RESULTS OF THE DEVICE.
Motion
DF
(ROM)
PF
(ROM)
Inv
(ROM)
Eve
(ROM)
MTP joint
(ROM)
DF
(Torq)
PF
(Torq)
Inv
(Torq)
Eve
(Torq)
Spec 20 40 35 25
Flex (45)
Ext (70)
40.7-
97.6Nm
20.3-36.6
Nm
Max
48Nm
Max 34Nm
Designed 50 55 70 104Nm 248Nm
TABLE II
MINIMUM AND MAXIMUM ACHIEVABLE STIFFNESS
f
z
K
f
K
K
r
z
K
r
K
Minimum 4.5kN/m 0.25kNm/rad 0.05kNm/rad 4.5kN/m 0.1kN/rad
Maximum 200kN/m 6.5kNm/rad 2kNm/rad 200kN/m 2.5kNm/rad
32
TABLE III
IMPEDANCE PARAMETERS FOR EACH EXERCISE MODE
ROM (stretching)
Strengthening
Proprioception
Impedance
parameter
PROM AAROM AROM Isometric Isotonic Isokinetic AROM + Isometric
Z
Z
inf
Z
zero
- Z
inf
Z
zero
Z
inf
Z
const
Z
inf
Z
zero
at orientations
Z
inf
at position
X
d
Vari Vari Const Vari Vari Const (static)
or Vari (dynamic)
d
X
&
Zero Zero
N/A
Zero Vari Const Zero (static)
or Const (dynamic)
Control
type
Position
Variable
Impedance
N/A
Position
Position
based force
Velocity
Wobble board motions
Exercise
Example
Stair input
Stair input
with visual
feedback
N/A
Image
viewer
Heel
raise
Gait
generation
Ball stabilization