Afstudeerverslag ArjenBergsma

Univerrsity of TTwente

DESIIGN O
OF A
A WEA
ARABLE ARM
M
SU
UPPO
ORT WWITH PA
ASSIV
VE
GR
RAVIT
TY COMP ON
PENSSATIO

Exam committtee:
Prof. dr. ir. H.F.J.M. K
Koopman
Ir. D.J.B.A. Kranenburg ‐ de Lange
Ing. M.I. Paaalman (VU A
Amsterdam)
Dr. ir. JJ.L. Herder (TU
U Delft)
Dr. ir. J. Harlaar (VUMc A
Amsterdam)
A
Arjen B
Bergsm
ma
une 30th, 200
Ju 09

June 30th, 2009 [DESIGN OF A WEARABLE ARM SUPPORT]

2 Preface | University of Twente

[DESIGN OF A WEARABLE ARM SUPPORT] June 30th, 2009
PREFACE
This study is part of the project ‘Flextension’ which was started by Paalman and Abell of the VU medical centre
in Amsterdam. The objective of this project is to design an unnoticeable orthosis which is able to adapt to the
progressive loss of muscle force in DMD. The project envisions reaching its goals in three steps. The first part
focuses on the design of a wearable non‐powered orthosis. The second part aims to add actuation to provide
extra power required to support the most affected patients. Finally, an interface that detects the users’
intention to make a movement should be realized. This study focuses on the first part. The objective was to
design the mechanical part of a wearable non‐powered orthosis, which is unnoticeable (so it is not socially
obstructing) and enables functional movements. To achieve this goal, there has been a cooperation with
researchers from the Biomechanical departments of the Universities of Twente and Delft, researchers from the
Movement Science department of the VU University in Amsterdam, researchers in rehabilitation science,
children rehabilitation physicians, physio‐ and occupational therapists who care boys with DMD, orthopaedic
experts and of course potential users themselves.
University of Twente | Preface 3


4 Preface | University of Twente

ABSTRACT
Duchenne muscular dystrophy is a progressive disease diagnosed in childhood. Muscles of the lower extremity
are affected first. At an age of about 12 years, most children need a wheelchair to move around. After affection
of the lower extremity muscles, the muscles of the shoulder girdle and the arms follow. Execution of daily tasks
like eating becomes an increasing challenge. There are devices available to support the arm function, but
because of the large dimensions, these devices are not suitable for adolescents who try to live their life as
normal as possible despite the disease they have.
This paper presents the design of a new wearable passive arm orthosis which is less noticeable than existing
devices and forms therefore no social barrier. This is the first part in the development of a wearable and active
orthosis which can be worn underneath the clothing.
The appendices contain more background information about Duchenne muscular dystrophy, the
kinematics/dynamics of arm movements and statically balanced systems. Furthermore, an overview of existing
devices can be found and the design trajectory is described in more detail.
University of Twente | Abstract 5


6 Abstract | University of Twente

FIGURE LIST
FIGURE 1 MAN USING THE ARMON [1] .................................................................................................................... 11
FIGURE 2 GIRL WITH ARTHROGRYPOSIS USING A WEARABLE WREX [2] .......................................................................... 11
FIGURE 3 CONCEPT I, II AND III .............................................................................................................................. 13
FIGURE 4 DRAWING OF THE FINAL PROTOTYPE .......................................................................................................... 15
FIGURE 5 ALIGNMENT MECHANISM IN TWO DIFFERENT ORIENTATIONS ........................................................................... 15
FIGURE 6 PERSON USING THE FINAL PROTOTYPE CONNECTED TO A CORSET ...................................................................... 16
FIGURE 7 OTHER ORIENTATION OF PARALLELOGRAM .................................................................................................. 18
FIGURE 8 WIDER ARM CUPS .................................................................................................................................. 19
FIGURE 9 TWO DIFFERENT ELECTRICAL WHEELCHAIRS USED BY DMD PATIENTS, LEFT: MODERN MODEL [51],
RIGHT: TRADITIONAL MODEL [1] ................................................................................................................ 29
FIGURE 10 TWO DIFFERENT VERSIONS OF THE WREX [2] .............................................................................................. 31
FIGURE 11 BALANCER DESIGN (A) [4], WHEELCHAIR VERSION (B) [1], OFFICE VERSION (C) [1] .............................................. 32
FIGURE 12 DAMPACE ELBOW AXIS (RIGHT) [13] .......................................................................................................... 33
FIGURE 13 WILMER ELBOW ORTHOSIS [61] .............................................................................................................. 34
FIGURE 14 PROTOTYPE OF ERGONOMIC EXOSKELETON [64] ........................................................................................... 35
FIGURE 15 LATEST VERSION OF RUPERT [65] ............................................................................................................ 35
FIGURE 16 MUSCLE SUIT OF KOBAYASHI [66] ............................................................................................................. 36
FIGURE 17 ROBOTIC SUIT OF PANASONIC [67] ............................................................................................................ 36
FIGURE 18 HAL‐5 [20] .......................................................................................................................................... 37
FIGURE 19 PLANES OF THE BODY [73] ....................................................................................................................... 39
FIGURE 20 ANATOMY OF THE UPPER LIMB. ANTERIOR VIEW: (A) BONES, (B) MUSCLES [72] ................................................. 40
FIGURE 21 DEFINITION OF THORACOHUMERAL ROTATIONS [8] ....................................................................................... 41
FIGURE 22 PARAMETERS OF THE DENAVIT‐HARTENBERG REPRESENTATION....................................................................... 43
FIGURE 23 KINEMATIC FRAME DEFINITION FOR THE JOINTS ............................................................................................ 44
FIGURE 24 EXAMPLES OF POTENTIAL ENERGY STORAGE ELEMENTS USED IN STATICALLY BALANCED MECHANISMS:
COUNTERWEIGHT (LEFT) AND SPRINGS (RIGHT) [83] ..................................................................................... 47
FIGURE 25 BASIC GRAVITY EQUILIBRATOR [15] ........................................................................................................... 47
FIGURE 26 GRAVITY EQUILIBRATOR WITH MORE THAN ONE BEAM [17] ............................................................................ 48
FIGURE 27 MECHANISM OF THE BALANCED ANTHROPOMORPHIC ROBOT ARM [16] ............................................................ 48
FIGURE 28 SKETCH OF THE BALANCE MECHANISM ........................................................................................................ 49
FIGURE 29 FORCES WORKING ON THE FOREARM .......................................................................................................... 49
FIGURE 30 FORCES WORKING ON THE BAR ALONGSIDE THE FOREARM .............................................................................. 50
FIGURE 31 FORCES WORKING ON THE UPPER ARM ....................................................................................................... 51
FIGURE 32 FORCES WORKING ON THE BAR ALONGSIDE THE UPPER ARM ............................................................................ 51
FIGURE 33 OVERVIEW OF THE FORCES IN THE SAGITTAL PLANE (LEFT) AND IN THE FRONTAL PLANE (RIGHT).............................. 53
FIGURE 34 USE OF TWO PRESSURE SPRINGS ................................................................................................................ 61
FIGURE 35 USE OF PARALLELOGRAM CONSTRUCTION WITH TENSION SPRINGS ................................................................... 62
FIGURE 36 USE OF PARALLELOGRAM WITH ONE TENSION SPRING AND HORIZONTAL ORIENTATION OF FOREARM ....................... 63
FIGURE 37 UPPER ARM FIXED AND THE FOREARM IS SUPPORTED WITH AN ORTHOSIS LIKE THE WILMER ORTHOSIS .................. 64
FIGURE 38 INFLATABLE CONSTRUCTION ..................................................................................................................... 65
FIGURE 39 CONSTRUCTION USING BOWDEN CABLES ..................................................................................................... 66
FIGURE 40 STATICALLY BALANCED MECHANISM WHICH SUPPORTS THE ARM AT ONE POINT ................................................... 67
University of Twente | Figure list 7

FIGURE 41 BOSTON BRACE ...................................................................................................................................... 68
FIGURE 42 THORACIC LUMBO‐SACRAL ORTHOSIS (LEFT), CERVICO‐THORACO‐LUMBO‐SACRAL ORTHOSIS (MIDDLE)
AND THE JEWETT BRACE (RIGHT) ............................................................................................................... 68
FIGURE 43 UPPER ARM PROSTHESIS [18] ................................................................................................................... 69
FIGURE 44 DIFFERENT KINDS OF WHEELCHAIRS ............................................................................................................ 70
FIGURE 45 LEGO MODEL OF THE CHOSEN IDEA ............................................................................................................ 70
FIGURE 46 CONCEPT I ............................................................................................................................................ 71
FIGURE 47 CONCEPT II ........................................................................................................................................... 72
FIGURE 48 CONCEPT III .......................................................................................................................................... 73
FIGURE 49 PHOTOS OF THE PROTOTYPE 1 ................................................................................................................... 75
FIGURE 50 SOLIDWORKS DRAWING OF THE FINAL PROTOTYPE ........................................................................................ 77
FIGURE 51 TEST SETUP ........................................................................................................................................... 78
FIGURE 52 ORIENTATION OF THE ALIGNMENT MECHANISM WITH UPPER ARM DOWN .......................................................... 80
FIGURE 53 LIMITED ROTATION ANGLE ELBOW ............................................................................................................. 80
FIGURE 54 TEST WITH A PERSON WITH DMD .............................................................................................................. 81
FIGURE 55 ALTERNATIVE ORIENTATIONS OF ALIGNMENT MECHANISM .............................................................................. 83
FIGURE 56 WIDER ARM CUP .................................................................................................................................... 83
8 Contents | University of Twente

CONTENTS
PAPER ......................................................................................................................................................... 10
INTRODUCTION ...................................................................................................................................................... 11
METHOD .............................................................................................................................................................. 12
REQUIREMENTS ..................................................................................................................................................... 12
CONCEPTS ............................................................................................................................................................ 13
DESIGN ................................................................................................................................................................ 14
EVALUATION ......................................................................................................................................................... 16
DISCUSSION .......................................................................................................................................................... 17
CONCLUSION ......................................................................................................................................................... 20
ACKNOWLEDGMENT ............................................................................................................................................... 21
REFERENCES .......................................................................................................................................................... 22
APPENDICES ................................................................................................................................................ 26
I. DUCHENNE MUSCULAR DYSTROPHY ................................................................................................................. 27
II. REVIEW ON ARM SUPPORTING SYSTEMS ............................................................................................................ 31
III. ARM KINEMATICS/DYNAMICS ......................................................................................................................... 39
IV. STATICALLY BALANCE .................................................................................................................................... 47
V. REQUIREMENTS ........................................................................................................................................... 55
VI. DESIGN ...................................................................................................................................................... 61

University of Twente | Contents 9

PAPER
10 Paper | University of Twente

I NTRODUCTION
Duchenne Muscular Dystrophy (DMD) is caused by mutations of the dystrophin gene, which is located on the X
chromosome, and is responsible for the connection of muscle fibers to the extracellular matrix. The disease
only affects boys and is the most common fatal genetic disorder diagnosed in childhood, affecting
approximately 1 in every 4000 live male births [3]. DMD is a progressive disease which starts with affecting the
muscles of the lower extremity, leading to loss of the ability to walk at the age of 12. It is followed up
weakening the muscles in the higher regions of the body. Eventually respiratory muscles are involved. The life
expectancy typically ranges until the mid‐30s.
Adolescents with DMD suffer from mild to severe loss of muscle function. At a certain age, the shoulder and
elbow muscles become too weak to lift the arm and hand against gravity. Consequently, the independent
execution of daily activities is strongly impeded.
There are various assistive devices available to support the upper extremity in people with loss of muscle
function. These can be subdivided in three main groups [4]: robotic manipulators, powered orthosis and non‐
powered orthosis which typically support the arm by static balancing using springs. In the early stage of DMD,
when the muscles of the upper arm become weaker, people may benefit from a non‐powered orthosis to
maintain some arm function. In this stage, people still have some muscle force, but it is not sufficient to lift the
arm. The use of an orthosis which compensates the gravitation force working on the arm enables a patient to
use his own muscles as long as possible.
When the muscle power becomes too weak, a higher degree of support is needed.
A device which is able to deal with changing muscle power has not been found in
literature. There are non‐powered orthosis, like the Armon [4], from which the
supporting spring force can be changed manually to deal with changing mass due
to for example emptying a cup of tea by drinking it. This adaptation is also used for
lifting the arm itself. Although it enables the user to lift the arm, this manner of
adaptation is not intuitive. The user has to change the spring force by a joystick in
his other hand when he wants to move the arm, instead of thinking about the arm
movements. Intuitive control is considered as an important requirement for upper
extremity prosthetics [5]. Beside the lack of intuitive control, the manual
adaptable devices are still not suitable for the most severe patients.
According to Grootenhuis et al [6], who F IGURE 1 MAN USING
investigated the quality of life experienced by THE A RMON [1]
people with a severe muscle disease, the

social wellbeing is an important issue. It is reasonable to assume that a
wearable device which is not noticeable from the outside will have a
positive effect on the social wellbeing of young men with Duchenne. This
is in concordance with ideas of the association of Duchenne patients [7],
which mentions the importance of the patients’ ability to independently
fulfil daily tasks by using their own hands without a noticeable device.
F IGURE 2 GIRL WITH In literature, one passive wearable arm support, the WREX[2], was found,

ARTHROGRYPOSIS USING A WEARABLE
see figure 2. The researchers reported several problems with the device.
WREX [2]
Due to misalignment of the elbow joint and the device, most users had
trouble with flexing the elbow close to the mouth. Furthermore, pronation/supination of the arm is not

University of Twente | Paper 11

supported, which makes getting food to the mouth quite challenging. Furthermore, some users experienced
social obstruction caused by negative reactions from peers at school.
In this paper the requirements, the design and the preliminary evaluation of a new wearable arm support are
described.
M ETHOD
Before the design of a non‐powered orthosis was started, the desired functions and requirements of the
orthosis are listed and a literature study is executed to find out which devices are already available. Based on
these results, several ideas are generated. The movements of the arm can be divided in three motions in the
shoulder (elevation, plane of elevation and rotation) and two in the elbow (flexion/extension and
pronation/supination) [8]. Since the plane of elevation is not influenced by gravity, it does not need to be
supported. Although gravity has a small effect on the wrist and hand, support of the pronation/supination
motion is eliminated. This choice is made since support of this movement is complex and also because the
function of the hand subsists quite long by patients suffering from DMD.
Three concepts are realized by LEGO models and the advantages and disadvantages are compared. One
concept is selected and elaborated into a prototype. This prototype was tested with one subject and based on
these results, a second prototype was made. This final prototype was tested on several ways. Static trials were
executed to evaluate the balancing principle and the available range of motion (ROM). One healthy subject and
three persons with DMD have tested the prototype. Furthermore, two rehabilitation physicians were asked to
give their opinion about the potential of the prototype. The observations of the researcher and the feedback of
the subjects and the physicians are also used as preliminary evaluation.
R EQUIREMENTS
The requirements are classified in three categories, described by Plettenburg [9]; comfort, control and
cosmetics.
C OMFORT
The requirements concerning comfort are divided in physical effort and mental effort. To achieve physical
comfort, the interface and control forces should be low, slight misalignment between the human joints and the
joints of the device should be possible without any movement problems and the unbalance between both sides
of the body should be low. There are four requirements to keep the interface forces low. Shear stress on the
skin should be avoided. There is no information found about how much shear stress the skin could bear before
it will be damaged, but it is known that shear stress in combination with pressure can easily result in ulcer
formation [10]. Beside shear stress, the area around the shoulder and elbow joint should be kept free, the
densely innervated axilla area should be avoided and respiration should not be obstructed. To keep the control
forces low, the friction within the mechanism should be low.
To reduce the mental effort to a minimum, it is important that the control is intuitive to avoid long training
periods. Furthermore, donning and doffing the device should be easy to reduce the load on the caretakers and
the device should not harm user or caretaker.


[DESIGN OF A
A WEARABLE ARM SUPPOR
A RT] June 30tth, 2009
C ONTRROL
As mentioned in the in ntroduction, tthe device should be able to adapt to aa decrease of muscle force given the
progressiive character of DMD. Thou ugh, active addaptation is no ot applicable for the passivve orthosis, addjustment
of the supporting forcees should be p possible. The user should b be able to con ntrol the maniipulation of thhe hand in
on between taable and head
the regio d. Healthy perrsons have a larger workspace, but sincee people with h DMD are
seated in
n a wheelchairr, their availab ble workspacee is already limited. Accord ding to most p patients and p physicians
it would be importantt to be able to move the h hand from the e tabletop of the wheelchair to the heaad, so the
most impportant activities of dailyy living (ADL),, like eating//drinking, scratching the h
head and typping on a
keyboardd are supporteed. This corresponds with h humerus elevvation of 20 to o 65°, humeru us plane of ele evation of
60 to 80°, humerus rottation of ‐35 tto ‐65°, elbow w flexion of 45 to 124°, pron nation of 90 to
o 120° [10].
C OSMEETICS
Regardingg cosmetics, the volume, the appearan nce and the audibility
a are important. Too be unnotice
eable, the
device sh
hould have sm mall dimensio ons and it sho
ould be placeed close to th
he body. Subjective feedbaack of the
subjects and the rehaabilitation ph hysicians is ussed to evaluaate these reqquirements. TTo make weaarable use
underneaath the clothin ng possible, pprotruding parrts and sharp edges should be avoided. FFor the audibility, quiet
operationn of the jointts without the sound of brakes
b being applied
a or removed is reqquired. Distraccted from
these cossmetic requireements, the eenergy consum mption should d be low, to avvoid the neceessity of large actuators
and batteeries. Furtherm more, the devvice should bee easy to clean n.
F UNCTTIONS
The main n function of tthe wearable passive ortho osis is to proviide mobility to o allow the haand to perform tasks in
the regio
on between taable and head
d. This main function is diivided in fourr sub function
ns. The orthosis should
carry the arm, it should compensatee the weight o of the arm and hand, it sho ould support the user in mo oving their
hand and d it should pro
ovide the userr control to mo ove the hand..
C ON CEPTS
Several id
deas have been generated d, which have resulted in three concepts able to stattically balance e the arm.
The choicce for a mechanism which iis statically baalanced is madde since low eenergy consum mption is conssidered as
an imporrtant requirem
ment. When the
t arm is staatically balancced, just a sm
mall amount o
of energy is needed
n to
move thee arm. The con ncepts are sho
own in figure 3.

F IGURE 3 C ONCEPT I, II AND III
Univversity of Tweente | Paper 13

All three concepts use springs to balance the arm. Concept I has two springs, one to generate a moment
around the shoulder joint and one to generate a moment around the elbow joint. Spring 1 compensates the
weight of the forearm and the hand and spring 2 the weight of the total arm. Due to the parallelogram
construction, spring 2 is able to balance the upper arm even when the centre of gravity of the forearm moves
in case of rotation of the arm or flexion of the forearm; the angles α and β do not influence the required force
of spring 2. This principle is already demonstrated in 1936 [11] and is also used in orthotic devices [12, 13]
before. Concept I has four rotation angles. The base of this concept is similar to the WREX [14]. To overcome
alignment problems between the elbow joint and the orthosis, a double parallelogram mechanism as used for
the Dampace [15] is added. To reduce the visibility of the orthosis, the forearm part is placed on the inner side
of the arm.
Concept II has one spring along the upper arm and the forearm is stabilized in horizontal position.
Consequently, gravity has no influence on movements of the forearm. This is similar to the method used for
the TOP orthosis [16]. This concept has three degrees of freedom, two at the shoulder and one at the elbow. To
move the hand towards the mouth, the user elevates the upper arm to bring the hand at equal height as the
mouth. This concept also uses a double parallelogram mechanism to avoid alignment problems with the elbow
joint.
Concept III is based on the ARM [17]. This concept uses two springs, both placed close to the shoulder. The arm
is supported at one point, close to the wrist. Part of the weight of the arm is carried by the shoulder. Since this
concepts supports the arm only at one point, alignment with the elbow is not an issue.
Concept I is chosen, since it has the highest satisfaction to the requirements. The main disadvantage of concept
II is that the user is not able to move the hand in a natural way. Since the forearm remains in horizontal
position during all motions, the upper arm should be elevated to raise the hand. Concept III is difficult to wear
underneath clothing since it moves out of the arms plane. During rotation of the arm and flexion of the
forearm, this results in protruding parts. The motions of concept I are in the same plane as the arm, which is in
line with development towards a device which is wearable underneath clothing. Furthermore, as well upper
arm as forearm movements are supported. The design is further explained in the next section.
D ESIGN
Figure 4 shows a drawing of the final prototype. The long parallelogram in this figure is worn along the outside
of the upper arm. The upper arm is supported by part B, perpendicular to the upper arm, close to the elbow
joint. When the rotation point of the lower bar along the upper arm close to shoulder is properly aligned with
the shoulder joint, no shear stress will act on the upper arm during elevation of the arm. The orthosis is
attached to a corset by part A. To achieve perfect static balance, the origins of the two springs should be
vertical above the rotation points. To achieve this, part A and part E should remain vertical. By using several
parallelograms, vertical orientation of part E is achieved. The lower arm is supported just before the wrist by
part D. Part C rests on top of the forearm, to avoid the balancing mechanism from moving down. As well part C
as part D are perpendicular to the forearm to avoid shear stress acting on the skin. To reduce friction within the
mechanism, bearings are used between all moving parts.


[DESIGN OF A

F IGURE 4 D RAWING O OTOTYPE
OF THE FINAL PRO
The main n problem meentioned in otther orthosis is misalignme ent between tthe elbow join nt and the me echanism.

Misalignmment results in undesired shear stress on the forearrm and becau use of that, m
most users haad trouble
with flexiing the elbow w close to the mouth. This concept is able to deal witth the alignmeent problem b by using a
double parallelogram
p mechanism [15]. During motion of th he arm the ro
otation axis oof the elbow moves in
relation to
t the orthossis. With a doouble parallellogram mechanism, the ellbow axis can n move freelyy within a
certain area, see figuree 5. This makees it possible to move the fforearm free from obstruction. Since the rotation
point of the device is freely moveable, an extraa support on the forearm is required tto avoid the alignment
mechanissm from moviing down. Thiss is represented by part C in figure 4.

F IGURE 5 A LIGNMENTT MECHANISM IN
N TWO DIFFEREN T ORIENTATIONSS
To reducee visibility, the part of the orthosis alonggside the fore earm is on thee inner side off the arm. Thiis position

of the forearm part m makes movement during co ombined rotattion of the up pper arm and flexion of the forearm
When placed o
easier. W on the outer sside of the forrearm, the rottation point o of the orthosiss moves awayy from the
shoulder when rotatin ng the arm an
nd flexing thee forearm to keep aligned with the elb
bow. Since the
e forearm
moves toowards the shoulder, a leverage force is required. Due to the mass
m of the mechanism, it
i has the
tendencyy to move tow wards the shou ulder, so some energy is ne eeded for movving away from the shoulder. Placed
on the inner side of th he arm, the ro otation point moves towarrds the should der and no extra energy is necessary
to achievve this.
Gravity accting on the arrm and the proototype deliverrs a force on th
he mechanism
m, which shouldd be caught byy the body.
In this casse shear stresss on the skin should be avo
oided. To achieve this, the p
prototype corsset delivers th
he reaction
forces to a wide area, by enclosing thee whole trunk (see figure 6).

Univversity of Tweente | Paper 15


F IGURE 6 P ERSON USING THE FINAL PROTOTYPE CONNECTED TO A CORSET
E VALUATION
Results of the tests, observations of the researcher and the subjective feedback of users and experts are used
to evaluate to what extent the prototype satisfies the requirements.
C OMFORT
Although, the supporting forces were delivered perpendicular to the upper arm and forearm, slight shear stress
was experienced at the upper arm during abduction of the arm and at the forearm during rotation of the upper
arm. Regarding obstruction of the respiration, some pressure was felt on the chest, caused by the corset. The
shoulder and elbow joint were kept free even as the axilla area. Slight misalignment between the elbow axis
and the orthosis was possible. Though, after rotation of the arm followed by flexion of the forearm, the
alignment mechanism reached its shortest length which made it not possible to reach the head with the hand.
Furthermore, the elbow axis could move freely along a certain distance when the upper arm was elevated. The
distance was about 6cm when the upper arm was elevated 90° and at 10° (arm down) or 170° (arm up) this
distance was about 0cm. For the shoulder, no measures were taken to reduce misalignment problems. The
prototype weights about 1kg. This weight was only delivered on the right side of the body. Friction within the
mechanism is below 0.1N. This has been established by measuring the force required to move the upper arm
part in case a weight of 0.5kg was hanged on the forearm. Taking on and taking off the device was experienced
as easy. The orthosis exists of one part which can be fastened by straps. Regarding safety, the device does not
satisfy yet. During donning or doffing of the system, the pretension in the springs can result in undesired
movements of the mechanism, which could hurt the user.
C ONTROL
Control of the device was experienced as intuitive. The ranges of motion in which the arm could be moved are
determined by observations of the healthy subject. The range of humerus elevation was 10 to 100°, plane of
elevation was 50 ‐ 90° (0 and pronation was 0 ‐ 180°. The ranges of upper arm rotation and forearm flexion are
more difficult to describe, since these depended on the other angles. Rotation of the upper arm was ‐90 ‐ 50°
(0° is defined as forearm in front of the chest) when the upper arm was elevated 90° and the forearm was
flexed 30°. In case of humerus elevation of 90° combined with forearm flexion of 90°, rotation of the upper arm
was not possible. Flexion of the forearm was about 70° when the humerus was elevated 90°. In case of
humerus elevation of 10° combined with humerus rotation of 0° it was about 60° and when the humerus was
elevated 90° and the was humerus rotated 0°, it was about 20°.
Though, users were not yet able to move in the total range between the table and the head, some functional
movements were already supported. One of the subjects with DMD had problems with getting the hand on the

table. This movement was important for him to be able to use the keyboard of the computer. To achieve this,
he needed to sustain his elbow on the rest of the wheelchair, flex his forearm slightly (he had enough muscle
force to do this), put his hand on the table and subsequently walk his hand on the table by using the fingers.
When using the prototype, he was able to place his arm on the table with much less effort.
C OSMETICS
The dimensions of the prototype were experienced as small by the subjects and rehabilitation physicians. There
has also been mentioned that the design was an improvement compared to other devices. One of the subjects
had tried other devices before, but was not willing to use any of them, since these devices should be attached
to his wheelchair. He mentioned that this prototype has a better appearance then other devices he had seen
before.
The placement of the forearm part of the orthosis is on the inner side of the arm, which is different from other
devices. According to the subjects and the rehabilitation physicians, this makes the device less noticeable and is
therefore an important advantage. The placement of the forearm part on the inner side of the forearm was
experienced as an important advantage. Although the device is placed close to the body and there are no
protruding parts or sharp edges, the dimensions of the prototype are not yet small enough to make wearable
use underneath clothing possible. The audibility requirement was satisfied, since no noise in the joints was
heard during operation of the mechanism. Finally, cleaning the mechanism is not easy. This has not been
tested, but since the mechanism consists of many parts and it has in total 30 bearings, which are not covered,
this is considered as difficult. Although the bearings contain a small amount of lubricant, no problems are
expected with increasing friction when the device would be cleaned.
Since only springs are used for balancing the arm, there is no energy loss within the system and so the energy
consumption is zero. In theory no energy was required to keep the upper arm stable during flexion of the
elbow or rotation of the upper arm [11]. This effect has been tested for the prototype and a similar result was
found. The required force to remain the upper arm part in the same position changed with less than 0.1N, even
when the weight on the forearm part moved relevantly to the elbow joint. To test the balance quality, a weight
of 0,9kg was placed on the upper arm part and a weight of 0,5kg was placed on the forearm part. The vertical
force which was needed to balance the upper arm part was ‐2,94N – 0N in the range between 10 ‐ 70°, 0N ‐
2,94N in the range 70 ‐ 90° and 2,94N – 9,81N in the range 90 ‐ 140°. To balance the forearm, a vertical force of
‐0,98N – 0N was needed in the range 0 ‐ 30° and 0N – 2,94N in the range 30 ‐ 90°.
F UNCTIONS
The main function of the orthosis was to provide mobility in the region between table and head. Some mobility
is already achieved, since users were able to get the hand on the table. Some problems arose to get the hand
close to the mouth. The prototype was able to carry the arm and it partially compensated the weight of the
arm and hand. Support in moving the hand was achieved when moving the hand on the table and the user was
able to control the device with the own muscles.
D ISCUSSION
The goal of this study was to design the mechanical part of a wearable non‐powered orthosis, which is
unnoticeable (and so socially not obstructing) and enables functional movements. As mentioned in the
evaluation, the final prototype does not satisfy all requirements yet. First, the requirements will be discussed
and at the end of this section several recommendations are placed to improve the device.

Slight shear stress was experienced at the upper arm. This is caused by the fact that the prototype has just two
degrees of freedom around the shoulder. When the upper arm is abducted (movement in the plane of
elevation), a degree of freedom is missing above the shoulder. Besides, perfect alignment of the shoulder joint
and the device is hard to achieve. During movement of the upper arm, this results in slight displacement of the
upper arm in relation to the cup. However, an alignment mechanism as used for the elbow joint is not
necessary, since the axis of the shoulder does not move a lot during motions between the table and the head.
Moreover, when the alignment mechanism for the elbow works properly, it is reasonable to assume that this is
sufficient to deal with the alignment problems. At the forearm, some shear was experienced during rotation of
the upper arm. During this motion, the axis of the elbow moves laterally (away from the bodies’ midline), while
the orthosis remains in the same position. Besides shear stress acting on the arm, there was some pressure
observed on the chest during the test with the healthy subject. When the respiratory muscles are weakened,
this could lead to problems with breathing and should therefore be avoided. Also some problems were
encountered with the alignment mechanism. During eating movements, the upper arm is elevated in the range
from 20° to 65° [10]. With the current alignment mechanism, the area in which the elbow axis could move
freely is largest when the upper arm is elevated 90°. At 10° and 170°, this area is about zero. There can be
concluded that the orientation of the alignment mechanism is not optimal. Furthermore, slight unbalance
between both sides of the body was experienced. The prototype puts only load on the right side of the body.
For short term usage this is no problem, but for long term daily use this could result in problems with the spine
and it could accelerate scoliosis development.
Users were already benefitted by the prototype, but the available ROM was not yet sufficient to enable a user
to move the hand in the total range between table and head. This should be improved. Although users and
physicians were positive about the appearance of the prototype, the dimensions are not yet small enough to
make wearable use underneath clothing possible. Also regarding safety and cleaning, some improvements are
necessary. Furthermore, the springs should be changed. For the prototype, springs which had not the right
properties were used. This choice was made, since these springs were available. Due to time limit, no specific
springs were ordered. Due to this, there was compensation of the weight of the arm, but the amount was not
equal at the whole range of movements. So, the arm was not in balance in every position.
Several recommendations are made to improve the device.
R ECOMMENDATIONS
To improve the attachment with the body, two recommendations could be made. For the prototype, a full
torso corset is used, which is not desirable. The corset can be replaced by a brace across the shoulder, resting
on the thorax to relief the shoulder and sustained in the waist to get
sufficient stiffness to bear the forces by the arm. This brace can be
fastened by straps. This method is also used for total arm prosthetics
[18]. Beside the use of another type of corset, the shoulder should be
fixated properly, to avoid undesirable movements. Since the muscles
covering the shoulder are weak, the shoulder is not kept in place rigidly
and artificial lifting of the arm can result in movement of the shoulder,
which makes proper alignment difficult. Attention should be paid to the
compensating movements that people with DMD make in the shoulder
to move the upper arm.
F IGURE 7 O THER ORIENTATION OF
PARALLELOGRAM

For the balancing mechanism there are also several recommendations for improvement. The parts of the
prototype are made from aluminium. Though aluminium is relative light and easy adaptable, it does not have a
high stiffness. To reduce the dimensions of the elements, a material which is light and stiff can be used, for
example carbon, titanium or a composite. Composites are light, they can provide stiffness in the desired
directions and it is possible to produce complex forms. The uppermost of the two long bars of the
parallelogram along the upper arm, is only loaded with pull forces and can be replaced by a thinner bar or
cable. The other bar is loaded by push forces and should therefore be thicker to resist these forces. This bar
should also have enough torsion stiffness to be able to resist the torsion forces which occurs during arm
rotation.
To align the axis of the elbow with the rotation axis of the orthosis, a double parallelogram construction was
used. The orientation of the mechanism could be changed to work more properly for low upper arm elevation
angles, like for example in figure 7. The dimensions of the elements should also be reduced to generate more
space for the forearm to move towards the body. Besides limited arm movements due to the alignment
mechanism, movement is also limited in case the forearm is in vertical position and the user wants to rotate
the arm. This is because the two rotation axes of the orthosis at the elbow cross each other. One of the axes
can be slightly translated to reduce this problem. At the shoulder, an extra rotation point should be added to
enable the user to abduct the arm.
To increase the rotation angle of the joint of the mechanism near the elbow, the shape of the elements should
be changed. The rotation angle which can be reached by the prototype is about 90°. This should be increased
to about 120°.
Further, the arm supports should diffuse the supporting forces to a
broader area on the arm. The used cups are too small and should be
made larger, see figure 8. The orthosis should also be covered to avoid
clothing get stuck between moving parts.
Besides further improvement of the non‐powered orthosis, actuation

and controlling of the device is necessary to deal with the progressive
character of DMD and to enable a person to lift a weight. The actuation F IGURE 8 W IDER ARM CUPS
and control should make it possible to adapt dynamically to deal with for example drinking a cup of coffee
(about 0.5 kg). A short overview of possibilities for actuation and control will be given.
A CTUATION
For a portable device, the relation between power and weight is important [19]. The majority of developments
of exoskeletons use DC motors [19‐22]. Although this is a well‐known technology and it has a precise control, it
has a relative high weight. Other devices use pneumatic actuators [19, 23‐25], which have a good power‐to‐
weight ratio. Pneumatic actuators have also been studied by several researches to optimize for the use in
robotic devices [17, 26, 27]. Beside these two types of actuation, hydraulic actuators [28], springs [29, 30],
bowden cables [31, 32] and hydro elastic actuators [33] are used. According to Ruiz et al, electroactive
polymers and artificial muscles are promising technologies for the actuation of orthotic devices, since it has a
low mass and a high power delivery [19]. The control is difficult due to nonlinear response and hysteresis, but
research for the use as artificial muscles is going on at the moment [34‐36].


C ONTROL SYSTEMS
In the past, robotic exoskeletons were controlled by kinematic or dynamic commands [19, 37]. Later,
neuromuscular signals as EMG, have been implemented in several prototypes [19, 21, 22, 38]. Though EMG
makes integration with the device possible, there are also several problems like interference in the muscle
activation level, noise etc. Especially for people who suffer from a neuromuscular disease, EMG cannot always
be used. Beside muscle activity, also brain activity could be used, for example EEG [19]. Recently devices have
been developed for computer game control, using EEG signals. The reliability of these systems is unknown, but
it shows that research is going on. The control of exoskeletons as assisting tools requires special considerations
as robustness, reliability and safety. The device should identify the intention of the user; analyze the
information in real‐time and compute the required mechanical power.
C ONCLUSION
Adolescents with DMD need support to compensate the lack of muscle force in the arms. For these people it is
important that they are able to fulfil daily tasks independently without a noticeable device. Therefore, a device
should be wearable, not noticeable from the outside and it should enable a user to make functional
movements. There is considered that a device should be statically balanced to avoid the necessity of large
actuators and batteries. In literature, no suitable device has been found.
The objective of this study was to design the mechanical part of a new wearable non‐powered orthosis, which
satisfies the cosmetic requirements. The final design is able to statically balance the arm by using two springs,
one to generate a moment around the elbow joint and one to generate a moment around the shoulder joint.
The device consists of four parts; a connection with the body, an upper arm part, a forearm part and a
mechanism to align the elbow joint with the joint of the device. Misalignment had been reported as an
important problem with available devices. This design is able to reduce these problems by using a double
parallelogram mechanism. The placement of the forearm part of the orthosis is on the inner side of the arm,
which is different from other devices. According to the subjects and the rehabilitation physicians, this makes
the device less noticeable than other devices. This is considered as an important advantage. One of the
subjects in the evaluation tried other devices before, but was not willing to use any of them, since these
devices should be attached to his wheelchair. He mentioned that this prototype has a better appearance then
other devices he had seen. This person was also able to get his arm on the table without problems when using
the prototype, which took him normally a lot of effort to do.


A CKNOWLEDGMENT
Many people have co‐operated in executing this study and I would like to thank those people for their effort
and enthusiasm during the last year. I would like to thank Micha Paalman, from the VU University of
Amsterdam, who initiated the project a year ago together with Nina Abell. Thanks to their voluntary effort, I
was able to fulfil my master thesis within this project. I would like to thank Micha also for his supervision during
the whole trajectory. I would like to thank Ditske Kranenburg‐de Lange from the Biomechanical Engineering
department of the University of Twente for her supervision, the critical comments to improve my report and
her positive encouragement, Bart Koopman, professor of the Biomechanical department, for his supervision
and the opportunity he gave me to do my master thesis within this project. Furthermore, I thank Just Herder
from the University of Delft and Jaap Harlaar from the VU University in Amsterdam for their supervision and
expertise.
The final prototype is made by employees of the department System Developing of the VU University of
Amsterdam and I am very thankful for their effort, the work they delivered and the practical support during
assembling the prototype. I would like to thank the employees of the plaster section of the VU medical centre
in Amsterdam, who made a corset for the prototype.
I would like to thank Imelda de Groot, children rehabilitation physician of UMC St. Radboud in Nijmegen,
Cathrien van Groningen children rehabilitation physician of Roessingh rehabilitation centre and the physio‐ and
occupational therapists working on the children rehabilitation section of Roessingh rehabilitation centre for
their practical input, John‐John de Koning of Roessingh Rehabilitation Technology for his ideas about the
attachment to the body and the children who were willing to test the prototype and who provided me with
good ideas. I would like to thank Justus Kuijer and Elizabeth Vroom in particular for their enthusiasm about the
prototype and the opportunity they gave to make a nice movie about using the prototype.
I also would like to thank all my colleagues and the employees at the Biomechanical Engineering department
for all the pie, cookies and the nice discussions about everything that crossed our minds. And Geert Monnink
and Wouter Abbas for their practical support during the construction phases of the prototypes.
Finally, I would like to thank my family for their interest in what I did and my father in particular for his support
with the development of the first prototype. We made the first model from scrap metal and this model has
formed the base for the final prototype.

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APPENDICES

26 Appendices | University of Twente

I. D UCHENNE MUSCULAR DYSTROPHY
Duchenne Muscular Dystrophy (DMD) is the most common fatal genetic disorder diagnosed in childhood,
affecting approximately 1 in every 4000 live male births[3]. In the Netherlands about 25 boys a year [39] are
diagnosed with Duchenne. DMD results in progressive loss of muscle strength which leads to serious medical
problems.
C AUSE OF DMD
The disease is caused by a mutation of the dystrophin gen, which is localized on the X‐chromosome. This
chromosome contains the genetic information, required for the production of the dystrophin protein. Because
males have just one X chromosome, a mutation of the gen cannot be compensated. Females have two X
chromosomes, so a mutation of a dystrophin gen on one of the chromosomes can be compensated by the
other chromosome. Therefore they mostly do not have clinical symptoms when one gene is mutated. By
recessive inheritance the disease can be transferred to the next generation by a mother, who does not have
any symptoms (genetic carrier).
The consequence of a defected dystrophin gene is a deficiency of the dystrophin protein in the muscle cell wall.
Dystrophin gives elasticity and stiffness to the muscle and without it, the muscle cells are damaged and finally
die. Muscle atrophy occurs and connective tissue comes in place [40].
C OURSE OF DMD
The course of DMD is fairly predictable and it can be divided in several stages [41, 42]. The first physical decline
in Duchenne appears when boys are very young. Weakness is most obvious in large muscles, for example leg
muscles and progresses over time to smaller muscles, like hand muscles. The Dutch Duchenne Parent Project
[42] distinguishes six stages of Duchenne.
• Phase 1 (0 to 3 years old): insignificant clinical symptoms
• Phase II (3 to 6 years old): little muscle weakness and begin of limitation of motion
• Phase III (6 to 10 years old): increasing muscle weakness and contractures
• Phase IV (10 to 12 years old): decreased walking ability
• Phase V (12 to 18 years old): adolescence phase; start using wheelchair, intensive physiotherapy,
respiratory problems, operative scoliosis correction, psychological problems
• Phase VI (> 18 years old): adult phase; most skeletal muscles degenerated, dependent of several
technical devices
P ROBLEMS IN DAILY LIFE
Muscle atrophy itself is not painful. Because the nerves are not affected directly, the sensation of touch and
other senses retain normal. Usually, the smooth, involuntary muscles controlling the bladder and bowel remain
intact and people with DMD have normal sexual functions.
Although some functions stay quite normal, the heart muscles can be weakened by lack of dystrophin which
results in cardiomyopathy (heart muscle weakness). The respiratory system is often debilitated. At an age of
about ten years, the diaphragm and the thoracic muscles may weaken which decreases the effectiveness of
moving air in and out the lungs. This does not directly bring about shortness of breathing, but it can result in
University of Twente | Appendices 27

several other problems like headaches, concentration difficulties, nightmares and difficulties with coughing. It
also increases the chance of infections [43].
Beside the physical symptoms, about 30% of the boys with DMD have problems with learning, although just a
few are seriously retarded. The problems occur in three general areas, attention focusing, verbal learning and
memory, and emotional interaction.
According to the young men with Duchenne, the quality of life is not experienced lower than for healthy people
[6]. The encountered problems are especially psychosocial[6, 44, 45]. These issues are at least as important as
the physical problems and include the need for quality care, personal independence, educational and
employment opportunities, meaningful relationships and sexual activity. The ability to find and obtain practical
aids is often difficult and can be aided by occupational therapists and care coordinators [45]
T REATMENT AND THERAPY
DMD is not curable and it has a progressive course. The treatment is focussed on resisting the symptoms.
Because of the positive effect on muscle strength, Prednisone is often used [46]. The children are treated from
rehabilitation centres that are specialized in muscle diseases. This treatment focuses on stimulation of the
physical and psychosocial development of the children. The rehabilitation physician coordinates the process
and is assisted by physiotherapists, occupational therapists, speech therapists, social workers or dieticians. In
some cases the patients are operated on a curvature of the spine. When the respiratory muscles debilitate, the
respiration can be supported artificially by a nose cap during the night or permanently by a small hole in the
trachea. Also the heart will be checked regularly. In case of abnormalities, support of the heart can be started
[47].
There is also a need for assistive devices. All boys with DMD need wheelchairs at a certain moment. At an age
of about 12, it is typical that a child uses a wheelchair full time [10].
For the arm function, there are several devices used to support the execution of activities of daily life [43, 48].
Since the course of DMD is fairly predictable, the amount of support at specific periods of time can be indicated
[49]. When a person with DMD reaches the age of about 12 years old, he needs a wheelchair full time. At that
moment the arm function is usually still sufficient for the execution of daily tasks like eating. About two years
later, the muscles in the shoulder became weaker, which makes lifting of the upper arm harder. This is often
compensated by trunk movements. A slight support to lift the upper arm would enable a person to make use of
the shoulder muscles to lift the upper arm for a longer period. Also the muscles around the elbow become
weaker and around the age of 16, assistance to flex the elbow would be beneficial. Generally, the dexterity in
the hand retains throughout the teenage years, but they lack sufficient arm strength to position the hand to
perform daily living functions.
The choice for currently available orthosis is rarely made at the moment it starts to be helpful, since people are
still able to fulfil daily tasks by using several compensation techniques and the use of available devices
increases the feeling of disability. This weighs in most cases heavier than the potential benefit. The result of
using compensation techniques and not using a support device is that the weakened muscles are used less. The
declined movements of the arms contribute to decreased mobility of the joints (contractures) and it is
expected that diminished use of muscles quickens the decrease of muscle tissue. This is in line with the general
accepted idea that a function will be lost when it is not used anymore (‘use it or loose it’). According to
physiotherapists, it would be beneficial for a person with DMD, to start with arm assisting devices when this
becomes helpful. This is about two years after the person is fully dependent on a wheelchair.

[DESIGN OF A
The main n problems in daily life of cchildren with DMD have a ssocial charactter[6]. It is asssumed that th he arsenal

of attach
hed devices to o the wheelcchair, to suppport the functtions of the person
p sittingg in it, is partt of these
problemss. Especially devices
d to asssist the arm function are to a large extent
e visible from the ou utside and
increase tthe feeling off disability. Sitting in a wheeelchair on itse elf does not diirectly results in the assumption that
the user of the wheelcchair has a serious disabilitty, since it is aalready a com mmon image aand there are even top‐
class athletics who are seated in a
a wheelchair. Due to severral extra deviices attached to the whee elchair the
disability of the user sseems more sserious. This iss in concordance with userr surveys, which have indiccated that
there is aa preference toward orthossis rather than n robotic assistive devices[5 50].

F IGURE 9 T WO DIFFEERENT ELECTRIC
CAL WHEELCHAI RS USED BY DMD
D PATIENTSS , LEFT : MODEERN MODEL [5 1], RIGHT :
TRADITION AL MODEL [1]
When a d device is not vvisible from the outside, it is reasonable e to assume tthat a person is willing to u

use such a
device att the momentt it becomes h helpful for him
m. To stimulatte the own m muscles as longg as possible, a passive
assistive orthosis woulld be most suiitable in the fiirst stages of DMD.
Universityy of Twente | Appendices 29



II. R EVIEW ON ARM SUPPORTING SYSTEMS
There are various devices to augment the loss of function in the upper extremity. These devices can be
subdivided in three main groups [4]: robotic manipulators, powered orthosis and non‐powered orthosis which
are typically based on static balancing using springs. There are several orthosis to support the arm function and
there are also passive assisting devices available. The following overview is a summary of current available
devices. It is not the intention to provide a complete outline which describes all devices individually, but to
identify whether there is a suitable instrument to support children with DMD. The devices are subdivided in
two groups, passive arm balancers and wearable devices.
A SSISTIVE PASSIVE ARM BALANCERS
The human arm consists of three parts, the upper arm, the forearm and the hand. Movement between the
forearm and the hand has a negligible influence on the balance of the total arm, so these two are considered as
one part. The arm can be balanced in two ways, by two lifting forces [14, 16, 52] (one to raise the upper arm
and one to raise the forearm/hand) or by using the shoulder to carry part of the weight of the total arm [4, 53‐
55]. Of both types, one example is described in further detail. The theory of balancing is further explained in
Appendix 4.
W REX
Rahman et al [13, 14] developed a passive gravity balanced functional arm orthosis with four‐degrees‐of‐
freedom, which is attached to the wheelchair and is energized by rubber bands. The purpose of the device is to
support people with a muscular dystrophy or atrophy in the execution of daily tasks.
The orthosis consists of two links connected in series. Each joint has 2 degrees‐of‐freedom, one about the
vertical axis which is unaffected by gravity and one about the horizontal axis. Both links consist of four bars to
ensure that the vertical ones exist at the end of each link.
Recently, the effect of the WREX has been evaluated on reaching performance among stroke survivors. There
could be concluded that the reaching performance was improved when using the device [56].
The WREX has been used as a wearable orthosis. Users wore a back orthosis on which the orthosis was
connected, see figure 2 [2]
The orthosis is passive and statically in balance and it has been used as a wearable device, though several using
problems have been reported.

F IGURE 10 T WO DIFFERENT VERSIONS OF THE WREX [2]

0th, 2009 [DESIGN OF A WEARAB
June 30 BLE ARM SU
UPPORT]
A R MO N
N
The Armo on is an arm ssupport developed by Herd der et al [1, 4,, 17]. The devvelopment hass been triggerred by the
desire to
o reduce the operating efffort associated with non‐p powered orthosis. The muscle force req quired for
overcomiing friction, baalancing errorrs and load ch hanges can be e substantial aand according to the researrchers, the
performaance of the Arrmon is betterr in compariso on with passivve non‐powerred orthosis. TThe study wass primarily
directed at people sufffering from sspinal musculaar atrophy (SMA). Beside tthis category,, people suffe ering from
other neuromuscular diseases, peo ople with certtain paralysiss and people suffering from
m or at risk of
o RSI are
mentioneed. The Armo on has been b brought on the market in aa wheelchair aand an office version [57]. A person
using thee wheelchair version is abble to adapt the amount of support actively, for example by a joystick
operated d with the oppposite hand. The office verssion does not have this funcctionality.
The Armo on consists off four bars forming a paralleelogram, as caan be seen in the figures beelow. On the bar which
carries th
he weight of tthe arm, a fittting is connectted in which tthe forearm rrests. The linkkage is balanced by two
springs lo
ocated around the base jo
oint of the mechanism. To
o adjust the balancer
b to th
he end mass, the fixed
attachmeent point of th he springs can
n be varied. In the wheelchaair version thiis is done by aan electric mootor and in
the officee version, it caan be done maanually by rottating a screw
w.
The devicce is based onn the notion that not the co omplete masss of the user’ss arm needs to o be carried in order to

achieve aa fully balanceed arm. Typiccally, the shouulder of a user can be usedd to carry part of the arm mass. The
concept hhas one fittingg. It does nott follow the co
ontours of thee users’ arm. It is connecteed to the wheeelchair at
hip heigh
ht from wheree it goes up towards the sho oulder and fin
nally to the hand. The upper arm of the u user hangs
down in rrest.
There can
n be concludeed that the Armon is staticaally balanced aand it can be used passivelyy. Nevertheless it is not
wearablee.

F IGURE 11
1 B ALANCER DEESIGN ( A ) [4], W RSION ( B ) [1], O
WHEELCHAIR VER OFFICE VERSION ( C ) [1]
T HERAAPEUTIC PPASSIVE A RM BALAN
NCERS
A lot of rresearch is deedicated to reehabilitative d
devices for the upper extreemity [19]. So ome focus onn the total
arm [21, 37, 58, 59], while others focus on specific partss of the arm
m [60]. The D
Dampace is chosen
c as
representtative for thiss category.
DAMPACE
The Dammpace is a passsive rehabilittative arm support, develo
oped by Stien
nen et al [15] which makess use of a
paralleloggram construcction to avoid d the problem m of misalignm
ment between the axis of th he orthosis an
nd the axis
32 Appendicess | University of Twente

of the elbow joint. It is designed for rehabilitative trainings of stroke patients and it combines functional
training of activities of daily living with force‐coordination training. The Dampace, has controlled braking on the
three rotational axes of the shoulder and one of the elbow. The exoskeleton can assist in identifying causes
behind the movement disorders of stroke patients, tackle these causes with isolated force‐coordination
training and then integrate the isolated training back into a functional, task‐specific training protocol. Due to
the elbow mechanism, see figure 12 exact alignment with the human joint is not necessary.
There can be concluded that the Dampace is statically balanced, but it is not wearable.

F IGURE 12 D AMPACE ELBOW AXIS ( RIGHT ) [15]
A SSISTIVE WEARABLE ORTHOSIS
There are many orthosis available to support the human arm or parts of it. Research on active wearable devices
to be used as a functional support has also been executed, for example by Hoffman et al. who developed an
actuated wearable upper extremity orthosis [50]. The Wilmer orthosis is described in further detail, since there
is a need for a passive device.
WILMER ORTHOSIS
The Wilmer orthosis [61], provides a moment around the elbow joint to assist people with a paralyzed elbow. A
spring is used to create a moment which almost compensates the weight of the arm. A small dynamic moment,
generated by a forward movement in the shoulder executed by the user itself, is enough to lift the arm. The
orthosis contains a mechanism to lock the elbow in an angle of 90˚ or 135˚. This orthosis is not directly suitable
for DMD patients, since it only takes the elbow joint into account. The generated force does not change when
the users’ upper arm moves, while the required force around the elbow to remain the angle between the
upper and forearm does. The orthosis has been highlighted, because of its dimensions. It is small enough to be
wearable underneath the clothes.
Although the orthosis is wearable, it is not statically balanced.

June 30 BLE ARM SU
UPPORT]

F IGURE 13
3 WILMER EELBOW ORTHOSISS [61]
T HERAAPEUTIC W E ORTHOSSIS
WEARABLE
Beside fu
unctional orthosis, research
h is going on o
on wearable ttherapeutic devices of which some are still in the
conceptuual phase [62, 63]. A few orthosis which reached the prototype staadium are selected and de
escribed in
more dettail.
ERGONOMIC ARM EXOSKELETON
Schiele et al [64] deveeloped a proto otype of an arrm exoskeleto on based on tthe kinematics of human arms. They
made a n nine degree‐off‐freedom mo odel of the huuman arm kine ematics and they used this model to devvelop, test
and optim mize the kinematic structure of the exosskeleton. The e device includ
des shoulder‐girdle, should der, elbow
and wristt motions and d it requires n
no exact alignnment to the human joint aaxis. The deviice is actuated with DC
motors. The research hers presenteed a prototyppe of their exoskeleton, but
b there is no commercial device
available. The purposee of the reseaarch was to deevelop a hum man arm exoskkeleton, taskeed to tele‐manipulate a
space rob bot. Beside th
his purpose, neurorehabilitation of patie ents suffering from injuries to the nervous system
(like strokke, traumatic brain injury, o
or spinal cord injury) has beeen mentioneed as applicatiion by the researchers.
Schiele described amo ong other thin
ngs the probleems with exissting exoskeleetons and he examined in detail the
kinematiccs of the hum
man arm. This has been done
d to develop a new erggonomic exosskeleton that does not
interact w
with the human arm. The resulting deviice can interaact with an un nprecedented d portion of thhe natural
limb workspace, includ ding motions in the shouldeer‐girdle, shou ulder, elbow, and the wristt. The exoskeleton does
uire alignment to the hum
not requ man joint axees, yet is able to actuatee each DOF o
of our redundant limb
unambigu uously and wiithout reachin ng into singulaarities.
The preseented device iis wearable, though it is no
ot statically baalanced.


F IGURE 14 P ROTOTYPE OF ERGONOMIC EXOSKELETON [64]
RUPERT
Sugar et al [65] developed an exoskeleton for upper extremity repetitive therapy. The device has 4 DOF
(shoulder elevation (flexion), elbow flexion, supination, wrist extension) and is actuated by compliant
pneumatic McKibben muscles. The movements are programmed on forehand and this enables the user to
practice these movements over and over. Although the device is wearable, it is not passively balanced.

F IGURE 15 L ATEST VERSION OF RUPERT [65]
INFLATABLE EXOSKELETONS
Kobayashi et al.[66] created a ‘muscle suit’ by using pneumatic McKibben actuators. The purpose of the
research was to develop a device for people with a paralysis. The actuators are weaved into the suit, so there is
no metal frame necessary. This makes it light and cheap. The idea of the exoskeleton is interesting, though
there are many difficulties to compete. At first, the range of motion; the full‐range abduction motion is
realized, but the other motions not yet. Beside the limited range of motion, slippage, slack of wear, tight fit,
difficulty in dressing/undressing are considered as problems. The muscle suit is wearable, but not statically
balanced.


F IGURE 16 M USCLE SUIT OF K OBAYASHI [66]
Another inflatable suit, based on the work of Kobayashi, is developed by the Japanese Kobe Gakuin University
in cooperation with the company Matsushita (producer of Panasonic). There is no scientific information
available about this device, but according to several websites there are plans to make it commercially available
[67] in the beginning of 2009.

F IGURE 17 R OBOTIC SUIT OF P ANASONIC [67]
F ULL BODY EXOSKELETONS
Several research groups are working on a full body exoskeleton [20, 68‐71]. One of them, the HAL‐5 is
commercially available and will be described in more detail.
H A L 5
HAL‐5 is a full body exoskeleton, developed by Japanese researchers under the direction of Sankai[20]. The HAL
has been developed in the first place as an assistive device for the lower limbs. In the 5th version, the arms are
also supported. Though, the support is not active, since it blocks the elbow joint enabling a person to carry a
higher load. The researchers claim that the exoskeleton can be used by people who suffer from muscular
weakness. The device is actuated by DC motors and it uses EMG for control. When EMG is not detectable the
robotic autonomous control system activates itself automatically once the user starts moving. A disadvantage
of the use of EMG control is that it requires a quite long period of training/fine tuning and for people with
Duchenne, it is reasonable to assume that the EMG is not usable at all, because of the degenerated muscles.
The HAL‐5 is a wearable device, but it is not a passively balanced.

[DESIGN OF A

F IGURE 18
8 HAL‐5 [20
0]
D ISCU SSION AN D CONCLU

USION
In table 1
1 the described devices are listed.
T ABLE 1 O VERVIEW OF THE PRESENTTED DEVICES

W
Wearable Passivee balance
ARMON
X
arm Passive arm balancers
WREX
X X
(functional)
Dampace
X
(therapeutic)
(therapeutic)
balancers
Passive
Wilmer
X
Wearable
orthosis
orthosis
Ergonomicc
X
rehabilita
Wearabl
arm
on
exoskeleto
e

Wearable Passive balance
RUPERT
X
Inflatable
X
exoskeletons
HAL‐5
X
body
exoskeletons
Full
The presented devices are developed with various purposes and have various application fields, so they are
difficult to compare. Most of the found solutions have a therapeutic purpose and are not suitable for functional
daily use. There are wearable instruments which are actuated, for example to make repetitive movements, but
these are not able to support movement of the hand to the mouth controlled by the user. The only statically
balanced device which can be used as a passive wearable orthosis is the WREX. However, there are several
problems indicated by the users. These are:
• Trouble with flexing the elbow close to the mouth, due to misalignment of the elbow joint and the
WREX
• Negative reactions from peers at school
• Pronation/supination of the arm is not supported; getting food in the mouth is a challenge
Since the support of pronation and supination is mentioned as area of investigation by the developers of the
WREX, there has been focussed on the trouble of flexing the elbow and the rise of negative reactions for this
research.

III. A RM KINEMATICS / DYNAMICS

The body is often sectioned along flat surfaces called planes. This makes it possible to describe the motions
between bones by the same methods used for robot kinematics[72]. The most frequently used body planes
are [73]:
• Frontal or coronal plane; divides the body into anterior and posterior parts
• Transversal plane; divides the body into upper and lower parts
• Sagittal or lateral plane; divides the body into right and left parts

F IGURE 19 P LANES OF THE BODY [73]
The movement of each joint can be defined as occurring in these planes, always starting from the anatomical
position as shown in figure 19.
Movement in the sagittal plane is called flexion–extension:
• Flexion; movement that reduces the angle between bones or body parts.
• Extension; movement that increases the angle between bones or body parts
Movement in the frontal plane is called abduction–adduction:
• Abduction; outward movement of the limb, away from the median plane of the body.
• Adduction; movement that brings a limb closer to the bodies median plane
Other movements are:
• Supination; rotation of the forearm so that the palm is facing up
• Pronation; rotation of the forearm that moves the palm down
• Rotation (internal or external); movement of a joint around the long axis of the limb
• Circumduction; circular movement in which flexion, abduction, extension and adduction are combined


A RM KINEMATICS
The upper limb comprehends the region from the shoulder to the fingertips and it is divided in three segments
(the upper arm, the forearm and the hand) linked together by three joints (the shoulder, the elbow and the
wrist). The segments are constructed by several bony parts. The upper arm is formed by the clavicle, scapula
and humerus. The forearm is formed by the radius and ulna and the hand by carpal bones, metacarpals and
phalanges [72].

F IGURE 20 A NATOMY OF THE UPPER LIMB . A NTERIOR VIEW : ( A ) BONES , ( B ) MUSCLES [72]
SHOULDER JOINT
The arm is connected to the torso by the shoulder joint. The medial end of the clavicles joins the sternum and
the distal end joins the scapula. Both scapulae do not have other bony connections with the torso; they are
attached to the thorax and the vertebral column only by muscles. The scapula and the clavicle together are
called the shoulder girdle. These girdles are very light and allow the upper arm a high degree of mobility, since
only the clavicle is attached to the skeleton and the scapula can move quite freely across the back of the
thorax. Beside of that, the socket of the shoulder joint (glenoid cavity) is shallow and poorly reinforced, so it
does not restrict movement of the humerus[73].
Usually, the movements of the upper arm are described in terms of flexion, extension, abduction, adduction
and rotation [72]:
• Flexion–extension; the range of motion of the shoulder in flexion from the anatomical position is
between 130˚ and 180˚, while in extension the range is between 30˚ and 80˚.
• Abduction–adduction; the shoulder can attain up to 180˚ of abduction and about 50˚ of adduction.
• Rotation; this is a rotation around the long axis of the humerus. Rotation can be medial (internal) or
lateral (external). Internal rotation can attain between 60˚ and 90˚, while external rotation can attain
90˚.

It can be difficult to describe a movement evidently in these terms, for example, when the arm is between
extension and abduction. For kinematic analysis of movements of the arm, Wu et al. recommended another set
of descriptions to describe the shoulder movements [8]. These are:
• Elevation; rotation around the axis fixed to the thorax and coincident with the Yt‐axis of the thorax
coordinate system. 0˚ is abduction, 90˚ is forward flexion.
• Plane of elevation; rotation around the axis fixed to the humerus and coincident with the Xh‐axis of
the humerus coordinate system.
• Rotation; rotation around the Yh‐axis of the humerus coordinate system. Internal rotation is positive
and external rotation is negative.

F IGURE 21 D EFINITION OF THORACOHUMERAL ROTATIONS [8]
ELBOW JOINT
The elbow joint links the upper arm and forearm. The forearm consists of two parallel long bones, the radius
and the ulna. Together with the humerus they form three different joints. Articulation between the ulna and
the humerus is possible due to the humero‐ulnar joint, between the radius and the humerus due to the
humero‐radial joint and between the radius and ulna due to the radio‐ulnar joint [73]. This set of joints
provides the forearm with two degrees of freedom [72]:
• Flexion–extension; flexion is the movement whereby the forearm approaches the upper arm and the
opposite movement is extension. The range of flexion–extension motion varies between full extension
(0˚) and active maximal flexion (140˚–146˚). The elbow can be passively flexed up to 160˚. However,
the angle range in day‐to‐day activities varies between 30˚ and 130˚.
• Pronation–supination; this is a rotation around the long axis of the forearm. The movements are
defined from a starting position with the elbow flexed at 90˚ and the hand parallel to the sagittal
plane, with the palm of the hand inwards and the thumb upwards. Pronation is the rotation that
brings the thumb to a more medial position and it has a maximum of 80˚. Supination is the rotation
that moves the palm upwards and has a maximum of 85˚.
THE WRIST JOINT
The wrist joint links the forearm and the hand. It is a multi‐joint complex, which may be considered as having
two degrees of freedom [72]:
• Flexion–extension; flexion of the wrist is the movement that allows the palm of the hand to approach
the forearm and extension is the opposite. Though, there are large differences between subjects,
generally the wrist can achieve up to 90˚ active flexion and about 80˚ extension.


• Abduction–adduction; this is the movement moves the hand either towards the ulna (adduction) or
towards the radius (abduction). Adduction reaches up to 40˚, while abduction does not exceed 15˚.

K INEMATIC REQUIREMENTS ORTHOSIS
Various studies have been executed to measure the range of motion of daily tasks and some studies measure
the range of motion to be able to develop an upper‐limb orthosis [22, 74‐77]. There are a lot of differences in
definitions and the analyzed movements. Besides, not al studies consider the complete upper extremity
anatomical chain (thorax, shoulder, upper arm, forearm, hand). This makes comparing of the results difficult.
Van Andel et al [10] presented a measurement method for 3D kinematic analysis of the upper extremity and
they include also the scapular movement. The main purpose of this study was to define a measurement
method based on a marker model that is clinically feasible, follows the ISB standards for anatomical calibration
of the marker model [8] and describes the complete upper extremity anatomical chain. Since this study uses
the ISB standards, it has been used to define the kinematic requirements of the new orthosis. The range of
motions (ROMs) for all executed ADL, are listed in table 1.
T ABLE 2 M EAN RESULTS OF TOTAL ROM DURING SEVERAL DAILY ACTIVITIES

Movement Angles
Humerus elevation 10±5˚ to 135±9˚
Humerus plane of elevation* 0˚ to 100˚
Humerus rotation ‐89±13˚ to 60±9˚
Elbow flexion 0±5˚ to 143±5˚
Forearm pronation** 35±20˚ to 161±16˚
The most important activity in daily life is eating and drinking. The mean angles for this activity are listed in
table 2.
T ABLE 3 M EAN RESULTS OF THE ROM TO MOVE THE HAND TO THE MOUTH

Movement Angles
Humerus elevation 20±5˚ to 65±10˚
Humerus plane of elevation* 60˚ to 80˚
Humerus rotation ‐35±25˚ to ‐65±5˚
Elbow flexion 45±10˚ to 124±1˚
Forearm pronation** 90±10˚ to 120±10˚
* The ROM of the motion plane of elevation has not been described in literature, therefore it is considered as 0
to 100˚ (0˚ is abduction and 90˚ is flexion)
** In this study, the anatomical position is defined as pronation of 0˚


[DESIGN OF A
D YNAM
MIC REQU IREMENT S ORTHOSSIS
With inveerse dynamics the associatted joint torq ques that lead d to a specificc movement, can be comp puted. The
kinematicc representattion of a movement is giveen and with the inverse dyynamics, the kkinetics respo onsible for
that movvement is derived. Various researchers h have compute ed this for several movements [22, 75, 78 8], but for
the analyyzed kinematics of van Anndel et al, thiis has not be
een done yet.. Since the vaalues of the computed
c
torques vary
v a lot beetween the different reseaarches and th he followed procedures
p off these reseaarches are
unknown n, the data of vvan Andel hass been used to o compute the e kinetics of the movementts.
First, a geographical
g m
model has beeen defined in
n the Roboticcs Toolbox off MatLab [79]]. The orientaations are
subscribeed by using the Denavitt‐Hartenberg parameters [80]. An orientation, Ai,, subscribed in these
parameteers is represen nted by:
Ai = Root z ,θi Transz ,di Transx , ai Root z ,α i
θi = anglee between xi‐1 and xi about zzi‐1.
di = distance from origin of link i‐1 to
o xi along zi‐1
ai = distannce between zi‐1 and zi alon
ng xi‐1
αi = anglee between zi‐1 and zi along xxi

F IGURE 22
2 P ARAMETERRS OF THE D ENAAVIT ‐H ARTENBERRG REPRESENTATTION
To repressent the different body seggments includ ding the shoulder joint and
d the elbow jo
oint, the parameters as
listed in ttable 3 are ussed. These aree based on thee 9 DOF modeel of the hum
man upper limbb, presented by Schiele
et al[64].


T ABLE 4 D ENAVIT ‐H ARTENBERG PARAMETERS

Link A D α θ
1 0 0 90˚ Θ1 = plane of elevation
2 0 0 270˚ Θ2 = elevation
3 0 ‐Lhumerus 90˚ Θ3 = rotation
4 0 0 270˚ Θ4 = elbow flexion
5 0 ‐Lforearm 0˚ Θ5 = pronation
6 0 ‐Lhand 0˚ Θ6 = ‐
A graphical representation of these parameters is shown in figure 23.

F IGURE 23 K INEMATIC FRAME DEFINITION FOR THE JOINTS


The parameters θ, d, a and α define the orientation of each link. θ is the variable corresponding with the
changing joint angles. To compute the inverse dynamics with the robotics toolbox, four parameters are
required to define each link. These are:
• Link masses
• Link lengths
• Link centre of gravities
• Link inertia’s
For the approximation of the masses, lengths and centres of gravity of the links, descriptions of Winter [81] are
used. The parameters of the body segments of the upper extremity are listed in table 5.
T ABLE 5 M= BODYMASS , H= BODYLENGTH , L= SEGMENTLENGTH

Segment Mass Length COG (proximal)
Trunk 0.497*M 0.288*H 0.500 * L
Clavicle N/A 0.129*H N/A
Upper arm 0.028*M 0.188*H 0.436 * L
Forearm 0.016*M 0.145*H 0.430 * L
Hand 0.006*M 0.108*H 0.506 * L
Since inertia has an effect on the body parts, this effect should actually be taken into account. But because the
magnitude of the torques due to inertia is relative small compared to the torques working on the joints, this
dθ
effect has been left out of consideration. The angular velocity is derived by ω = [rad / s] and the angular
dt
dω
acceleration by α = [rad / s 2 ] . The maximal angular acceleration during the analyzed movements is
dt
calculated and this was 0.6 rad/s2.
The arm segments are considered as a rod to define the order of magnitude of the inertia due to these
m ⋅ L2
segments. The inertia of a rod is I end = [kg·m 2 ] (m is the mass of a segment and L the length)
3
The inertia due to the upper arm, forearm and hand, is respectively 0.080, 0.027 and 0,006 kg∙m2, so the total
inertia on the arm is 0.113 kg∙m2. The torques working on the segments due to inertia are calculated by
τ = I ⋅ α[Nm] (I is the inertia working on a segment and α the angular acceleration in rad/s). The total
torque working on the arm due to inertia is 0.068 Nm.
The torques during dynamic movements without the effect of inertia are listed in table 6.


T ABLE 6 T ORQUES DURING DYNAMIC MOVEMENTS WITHOUT EFFECT OF INERTIA
Movement Hand to mouth Combing hair Reaching
Humerus plane of elevation 0 Nm 0 Nm 0 Nm
Humerus elevation (up/down) ‐9.5 to ‐2.9 Nm ‐13 to 0.1 Nm ‐14.7 to 1.1 Nm
Humerus rotation 1.9 to 2.7 Nm ‐0.5 to 4.0 Nm 0 to ‐1.3 Nm
Elbow flexion ‐4.3 to 0.8 Nm ‐4.7 to 3.1 Nm ‐4.6 to 1.7 Nm
Forearm pronation 0 Nm 0 Nm 0 Nm
(For the calculations, the hand is considered to be 0.5 kg heavier, to represent lifting for example a glass).
Since the order of magnitude of the inertia is relative small compared to the order of magnitude of the torques
during several daily activities, the influence of inertia is not taken into account.

IV. S TATICALLY BALANCE
Statically balanced mechanisms provide a static equilibrium by compensating a force through one or more
potential energy storage elements. This static equilibrium is provided throughout or at least in considerable
parts of its range of motion. The mechanism can be moved, if the inertia is not considered, without any
operating effort, even though considerable forces are present within the mechanism. This is possible through
the fact that the potential energy is constant [82]. The potential energy can be stored in two ways, by using a
counterweight or by using elastic elements. A counterweight is used for example in bridges and it provides the
bridge structure to move up and restore the energy when the bridge moves down. Elastic elements are used in
the well known Anglepoise desk lamp designed by Carwardine [11] which uses a spring to balance the mass of
the lamp, see figure 24 (right)

F IGURE 24 E XAMPLES OF POTENTIAL ENERGY STORAGE ELEMENTS USED IN STATICALLY BALANCED MECHANISMS :
COUNTERWEIGHT ( LEFT ) AND SPRINGS ( RIGHT ) [11]
The principle of static balancing will be explained by the basic gravity equilibrator, consisting of a beam with a
mass balanced by a spring, see figure 25.

F IGURE 25 B ASIC GRAVITY EQUILIBRATOR [17]
The beam is in equilibrium in every position if mgl = kar . This equilibrium condition is derived by using the
potential energy equations. To achieve perfect static balance, the potential energy should be constant
throughout the range of motion of the mechanism. The mass m attached to the lever l can rotate freely about
point A. An ideal spring (this is a spring that behaves according to the relationship F = kx and has zero free


length [12]) attached at point B, which is located vertically above A at distance a, and it is attached to the lever
at point C at a distance r from A. φ is the angle between a and l. The total potential energy of this system is
given by:
Vtot = Vmass + Vspring

1
Vtot = mgl cos ϕ + kL2
2
The length of the spring L can be derived from L
2
= a 2 + r 2 − 2ar cosϕ , this gives:
1
Vtot = mgl cosϕ + k (a 2 + r 2 ) − akr cosϕ
2
If mgl = kar, the total work is in every position of the bar constant. These energy principles can also be applied
on other balancers, like a counterweight bridge. There are various devices available to compensate the weight
of a human arm. Rahman et al [38] developed a mechanism based on the basic gravity equilibrator. Instead of
one beam, they connected two beams in a parallelogram setting, as in figure 26. In this situation, the potential
energy is constant.

F IGURE 26 G RAVITY EQUILIBRATOR WITH MORE THAN ONE BEAM [13]
Herder et al [12, 17] developed the balanced anthropomorphic robot arm, which uses two springs, based on
the mechanisms of Carwardine. The commercially available Armon, described in appendix II, uses the same
principle.

F IGURE 27 M ECHANISM OF THE BALANCED ANTHROPOMORPHIC ROBOT ARM [12]


[DESIGN OF A
B IOMEECHANICA L MODEL OF THE F INAL CON CEPT

The sprin
ng parameterss and the requ uired dimensions of the sevveral parts of the final conccept are deterrmined by
using freee body diagraams. The figurre below show
ws all parts o
of the mechan nism togetherr with the fou ur rotation
angles α, β, γ, δ.

F IGURE 28
8 S KETCH OF TTHE BALANCE M ECHANISM
The direcctions of the fforces on the fforearm are d
determined. TThere is assum
med that the aangle α in thiss picture is
similar to
o the angle α in the figure 2
29.
y
F2
rf x
A
r1 1
α
Felbow
Ff = m
mf ∙g
F1

F IGURE 29
9 F ORCES WO
ORKING ON THE FFOREARM
The foreaarm is in equillibrium when the moment due to F1 and F2 equals thee moment duee to Ff and Felbbow.
When F f ⋅ r f ⋅ sin α = F1 ⋅ r1 thee sum of the m

moments is zero. Force F1 is:
rf rf
F1 = − F f ⋅ ⋅ sin α = −m f ⋅ g ⋅ ⋅ sin α
r1 r1

June 30 BLE ARM SU
UPPORT]
The forcees on the foreearm bar of tthe mechanism
m are showed
d in the figurre below. Theere is assumed
d that the
angle α iss similar in both figures.

F IGURE 30
0 F ORCES WO
ORKING ON THE B
BAR ALONGSIDE THE FOREARM
by use of the potential

There is assumed that F2 is in the elbow joint. The magnitude of Fveer1 iss calculated b
energy eq quations. Wheen the total p potential energy in the syste em is constan nt, it is in equilibrium. Lv is tthe length
of the sprring.
V pot = E pot , F1 + E poot , F1 + E pot ,veeer = constannt

rf ⋅ s rf ⋅ r 1
⋅ cos α + m f ⋅ g ⋅ ⋅ cos α +
2
= −m f ⋅ g ⋅ k1 ⋅ Lv1 = constant
r1 r1 2
r f ⋅ (r − s) 1
= mf ⋅ g ⋅ ⋅ coss α + k1 ⋅ (a 2 + b 2 ) − k1 ⋅ a ⋅ b ⋅ coos α = consttant
r1 2
This is achieved when:
rf ⋅ (s − r ) rf ⋅ (s − r )
mf ⋅ g ⋅ = k1 ⋅ a ⋅ b andd so k1 = m f ⋅ g ⋅ which is cconstant.
r1 r1 ⋅ a ⋅ b
The forcee delivered byy a spring is givven by k ⋅ Δ L . In this situaation Δ L can

n be calculated
d by:
ΔL1 = a 2 + b 2 − 2 ⋅ a ⋅ b ⋅ cos α − a 2 + b 2 − 2 ⋅ a ⋅ b
To calculaate the k‐valu
ue of spring 2, the forces to support the u
upper arm aree determined. The forces w
working on
the upper arm are sho owed in figure 31.

[DESIGN OF A

F IGURE 31
1 F ORCES WO UPPER ARM
ORKING ON THE U
The uppeer arm is in eq
quilibrium wheen the sum off the momentts around the shoulder is zeero. Three forrces cause
a momennt around this rotation poinnt, Fu, F3 and FFelbow.
The required force F3 to balance the
t e arm is calculated by:
∑ M = −F u ⋅ ru ⋅ siin γ + F3 ⋅ r3 − Felbow ⋅ l ⋅ sin

s γ = 0 .
F3 can now be calculateed:
− Fu ⋅ ru − Fellbow ⋅ l − mu ⋅ g ⋅ ru − m f ⋅ g ⋅ l
F3 = ⋅ sin γ = ⋅ sin γ
r3 r3
The resullting forces on
n the upper arrm bar to balaance the arm aare showed in
n figure 32.

F IGURE 32
2 F ORCES WO
ORKING ON THE B M
BAR ALONGSIDE THE UPPER ARM


The k‐value of spring 2 is determined by the potential energy equations:
V pot = E pot , F3 + E pot ,veer = constant

− mu ⋅ g ⋅ ru − m f ⋅ g ⋅ l 1
⋅ u ⋅ cos γ +
2
= k 2 ⋅ Lv 2 = constant
r3 2
− mu ⋅ g ⋅ ru − m f ⋅ g ⋅ l 1
= ⋅ u ⋅ cos γ + k 2 ⋅ (c 2 + d 2 ) − k 2 ⋅ c ⋅ d ⋅ cos γ = constant
r3 2
This is achieved when:
mu ⋅ g ⋅ ru + m f ⋅ g ⋅ l mu ⋅ g ⋅ ru + m f ⋅ g ⋅ l
⋅ u = k 2 ⋅ c ⋅ d and so k 2 = ⋅ u which is constant.
r3 r3 ⋅ c ⋅ d
The force delivered by a spring is given by k ⋅ Δ L . In this situation Δ L can be calculated by:
ΔL2 = c 2 + d 2 − 2 ⋅ c ⋅ d ⋅ cos γ − c 2 + d 2 − 2 ⋅ c ⋅ d
Considering a person of 70kg and a length of 1,70m, the parameters are as overviewed in table 7. For the
masses and lengths, the scaling parameters of Winter are used (see appendix III.4).
T ABLE 7 P ARAMETERS TO CALCULATE REQUIRED SPRING PARAMETERS

mf 1.12 kg mu 1.96 kg
g 9.81 m/s2 g 9.81 m/s2
rf 0.11 m ru 0.14 m
r 0.04 m u 0.16 m
s 0.19 m r3 0.16 m
r1 0.15 m c 0.04 m
a 0.04 m d 0.17 m
b 0.03 m l 0.32 m
With these parameters, the required spring parameters are: k1 = 1007, k2 = 913, ΔL1 = 0.06m and ΔL2 = 0.08m.
The angles β and δ do not influence the required spring forces. Though, these angles have influence on the
reaction forces on the attachment with the body. For δ = 0˚, the forces on the attachment with the body are
only working in the sagittal plane (left part of figure 33). When δ = 90˚, there are also forces in the frontal plane
(right part).


F IGURE 33 O VERVIEW OF THE FORCES IN THE SAGITTAL PLANE ( LEFT ) AND IN THE FRONTAL PLANE ( RIGHT )


V. R EQUIREMENTS
For this thesis, a conceptual design of a new arm supporting device will be made. There are several methods
that can be used. In this case there has been chosen for the method described by Eger et al [83], because of the
systematically approach in conceptual design. Since some steps were not relevant for this study, they are left
out of consideration. The product design process can be divided in four phases: the pre‐phase, the design
phase, the detailing phase and the finishing phase. During this thesis, attention is paid to the pre‐phase and the
design phase. The pre‐phase comprehends an analysis of the stakeholders and the intended functions. Also,
the requirements are identified.
S TAKEHOLDER ANALYSIS
There are various users involved in the development of a new device for arm support of children with DMD.
Beside the primary users, who have the most interest in the device, there are also secondary users. In this case,
the persons who make the decision to buy the device are not the same as the persons who are going to use the
product. There can be remarked that a good usable device which does not attract the decision‐maker will not
be purchased, while a product which attracts the decision‐maker but is not good usable could lead to problems
for the users. So, as well potential users as people who decide which supporting devices should be purchased
for a specific person should be involved in the design process.
PRIMARY USERS
The primary users are:
• Adolescents with Duchenne, they
o would execute ADL independently
o would increase their social well‐being
o would like an esthetical and reliable device
• Parents/helpers of the people with Duchenne, they
o would like a device which decreases the load on parents
o would like a device which does not brings about much effort to don and doff
SECONDARY USERS
• Project group ‘Bewegen is Bijzonder’, they
o would like to develop a new active and wearable orthosis for the upper extremity for children
with Duchenne
• Orthopaedic companies, they
o would like a device which is commercially attractive to produce
• Healthcare professionals (e.g. Occupational therapist, physiatrists), they
o would like a device that is functional and feasible for an individual person
• Insurance companies, they

o would like a device which benefits outbalance the costs
• Government
o A medical device should be CE certificated before it can be brought on the European market
P ROGRAM OF REQUIREMENTS
Many researchers described requirements for an exoskeleton and the search for design requirements has
become a research field in its own [84]. According to Schiele [84], who did research on the fundamentals of
ergonomic exoskeleton robots, there are several problems with current devices, namely:
• Limitation of the available workspace
• Existence of positions of the mechanism where the behaviour cannot be predicted (singularities)
• Requirement of exact adjustment of linkages
• Discomfort
• Lack of portability
• Unknown performance of physical human‐robot interaction
He related these problems to the mass caused by exoskeleton actuation, wrong assumptions on the biological
kinematics of the human limb and on unknown real‐life variability of human subject’s anthropometry. These
problems are taken into account to define the requirements of a new device.
Plettenburg described three basic principles necessary for good prostheses design, cosmetics, control and
comfort [9]. Although, this research does not concerns the design of a prosthetic device, it is also relevant for
the design of an arm supporting device.
COMFORT
The requirements concerning comfort are divided in physical effort and mental effort.
LOW PHYSICAL EFFORT
There are four requirements regarding the physical effort:
Low interface forces
• Low contact pressures
o Regarding safety, pressure above the ischemic level should be avoided. This is the level at
which the capillary vessels are unable to conduct blood. Estimation of this level is 30mmHg
[72]
o Recommendations to avoid contact pressure problems are [72]:
Allow a free area around joints so that they have their full range of movement.
Avoid bony prominences, bony processes and tendons since bones in these areas
can act as stressors and increase the likelihood of suffering injury.
Avoid areas with surface vessels or nerves to limit the likelihood of injuries.
o Specifically for the upper arm the recommendations are:
Allow free space around the shoulder and elbow.

Avoid the highly innervated axillary space to avoid pain or discomfort.
The area between the elbow and the wrist has a low tolerance to pressure (average
ca. 450kPa).
• Low shear stresses on skin
o Contact forces directed perpendicular to the skin are fairly opposed by the skin. Contact
forces directed in the plane of the skin often lead to skin damage [9].
• Low obstruction for respiration.
o People with Duchenne disease often have respiratory problems.
Low control forces
• The muscle force required to control the device should be minimal.
Misalignment between the joint of the device and the human joints should be possible
Low unbalance between right and left side of the body
• The device should not induce or deteriorate scoliosis.
• The device should fit abnormal trunk morphology/anatomy.
LOW MENTAL EFFORT
Regarding the mental effort, there are two requirements:
Easy control
• Control of a device should be intuitive.
Easy to don and doff
• Donning and doffing by the user itself is not possible. Parents or helpers should support with this. Don
and doff should be easy to minimize the load on them.
CONTROL
As well as the motion as the force should be controlled.
CONTROL MOTION
The user should be able to manipulate the hand in the region table to head. The ranges of motion should be at
least:


T ABLE 8 R EQUIRED RANGE OF MOTION ( SEE A PPENDIX 3)

Movement Angles* Angles (wish)**
Humerus elevation 20±5 to 65±10 10±5 to 135±9
Humerus plane of elevation 60 to 80 0 to 100
Humerus rotation ‐35±25 to ‐65±5 ‐89±13 to 60±9
Elbow flexion 45±10 to 124±1 0±5 to 143±5
Elbow pronation/supination 90±10 to 120±10 35±20 to 161±16
* ROM of ADL eating/drinking ** total ROM[10]
CONTROL FORCE
A user should be able to carry 0.5kg in hand (for example a cup of coffee).
COSMETICS
Regarding cosmetics, the volume, the appearance and the audibility are important.
VOLUME
To reduce the volume, the dimensions of the orthosis should be small and the orthosis should be close to the
body
APPEARANCE
The orthosis should be unnoticeable and therefore, the device should be wearable underneath the clothing. It
is therefore important that there are no mounting nipples and other hard sharp edged parts.
AUDIBILITY
The operation of the joints should be silent, without the sound of brakes being applied or removed [5].
OTHERS
This fourth group is added, since not all requirements fitted in one of the three described by Plettenburg.
LOW ENERGY CONSUMPTION
The energy consumption should be low to avoid the necessity of large and heavy batteries
EASY TO CLEAN
Since the goal is to wear the orthosis underneath clothing, it is important that the device is not attractive to
dirt.
ACCESS ON THE MARKET
Medical device should fulfil safety requirements before it can be introduced to the market.


F UNCTION ANALYSIS
To be effective, the device should be able to support the user, who has almost no muscle strength in the arm,
in the execution of daily tasks. As mentioned in the first chapter, the device will be effective when the user is
able to manipulate the hand to the head, to manipulate the hands in a horizontal plane and to manipulate the
hands in a vertical plane.
Because the user does not have enough muscle strength to manipulate the hand appropriate, the device
should be able to give actuated support. The user should also be able to control the device by him‐ or herself.
For the new concept, several functions could be distinguished. The functions are divided in the main function
and in sub functions.
MAIN FUNCTION
• Provide mobility to allow the hand to perform tasks in the region table to head.
SUB FUNCTIONS
• Carry the arm
o Provide physical interface between human arm and device (linkages, suit, etc.)
o Cling to the arm (bands, cups, etc.)
• Compensate for the weight of the arm and hand
o Provide passive power (spring, mass, etc.).
• Move the endpoint (hand) through space
o Provide mechanical guidance (linkage, cable system, etc.)
o Provide active power (electric motor, pneumatic, human muscles, etc.)
• Provide control for moving the endpoint
o Control motion (trajectory control, human muscles, etc.)
o Control force (static balance, active force control, human muscles)
• Detect external environment disturbances
o Provide feedback (visual information, predefined, etc.)
• Compensate for disturbances to stabilize the arm
o Provide active power (electric motor, pneumatic, human muscles, etc.)
The last two sub functions are not relevant for the development of a passive orthosis and can be supplied in
the future.


VI. D ESIGN
During the design phase, several ideas have been generated and the main ideas are listed in paragraph A. There
is focussed on statically balanced mechanisms. This choice has resulted in three concepts, which are described
in more detail in paragraph B. Finally, the realisation and results of the two prototypes are described in
paragraph C and D.
A. I DEAS
Based on the requirements, eight concept ideas for lifting the arm with a wearable device are contrived. First,
there is mainly focussed on manners to lift the arm. At the end of this section, several ways to attach the
support mechanism to the body are presented.
I D E A I: T W O P R E S S U R E S P R I N G S

F IGURE 34 U SE OF TWO PRESSURE SPRINGS
Additional information:
• Part 1 and 2 are connected in the axilla, see right part of figure 34.
• Part 2 and 3 are joined together around the elbow.
• Part 3 consists a 2nd cup to enable the arm to translate in the part, to avoid shear stress
• Spring a causes elevation of the upper arm
• Spring b causes flexion between upper and lower arm

I D E A II: P A R A L L E L O G R A M W I T H T W O T E N S I O N S P R I N G S

F IGURE 35 U SE OF PARALLELOGRAM CONSTRUCTION WITH TENSION SPRINGS
• Spring between B and C causes elevation of the upper arm
• Spring between D and E causes flexion of the lower arm
• Elevation is possible since the vertical bar beside the trunk can rotate
• Due to the parallelogram, both the upper arm as the lower arm are balanced

I D E A III: P A R A L L E L O G R A M W I T H O N E T E N S I O N S P R I N G
The upper arm is balanced as in idea II. The forearm cup remains horizontal, so the forearm can flex without
support, since gravity does not influences this movement.

F IGURE 36 U SE OF PARALLELOGRAM WITH ONE TENSION SPRING AND HORIZONTAL ORIENTATION OF FOREARM

I D E A IV: F I X U P P E R A R M , B A L A N C E L O W E R A R M
Although, elevation of the upper arm is required to bring the upper arm to the mouth, dynamic elevation is not
at all costs necessary to support a person for example with eating. When the upper arm can be fixed at certain
degree of elevation, like a caravan window, only the forearm should be supported dynamically.

F IGURE 37 U PPER ARM FIXED AND THE FOREARM IS SUPPORTED WITH AN ORTHOSIS LIKE THE WILMER ORTHOSIS
• The upper arm is fixed (like a caravan window mechanism)
• The forearm is balanced with an orthosis

I D E A V: I N F L A T A B L E
Several researchers are working on orthotic devices using inflatable actuators, also called McKibben muscles.
Beside McKibben actuators, the orthosis itself can be made inflatable. There are tents available, using inflatable
sticks, able to carry the weight of the canvas. When an inflatable stick is pumped with a certain pressured, a
movement can be made.

F IGURE 38 I NFLATABLE CONSTRUCTION

I D E A V I: B O W D E N C A B L E S

F IGURE 39 C ONSTRUCTION USING BOWDEN CABLES

• One Bowden cable to induce shoulder elevation
• One Bowden cable to induce elbow flexion
• The cables are pulled by springs
• To balance the arm, there is a mechanism on the back which makes the spring force dependent of the
changed cable length.

I D E A V I I: S T A T I C B A L A N C E , S U P P O R T A T O N E P O I N T
The mechanism used in the Anglepoise lamp of Carwardine can also be used to balance the arm. Herder et al
developed the Armon which is based on this principle. For wearable and inconspicuous use, the construction is
not optimal. As can been seen in the picture below, the Armon has two bars going up from the base and this is
not comparable with the human arm. Therefore, the orientation of the mechanism is changed, as in figure 40.
This is comparable with the anthromorphic arm of Herder.
F IGURE 40 S TATICALLY BALANCED MECHANISM WHICH SUPPORTS THE ARM AT ONE POINT
• The arm is balanced by two springs at the base of the orthosis
• The arm is supported by one lifting force at the wrist


I D E A V I I I: I M P L A N T A B L E A C T U A T O R S
Beside orthotic devices, another option is to implant actuators to replace the muscles. The bones of a person
with Duchenne are not affected and can be used to direct the forces. A certain approach has been examined by
Kiguchi et al. [85, 86], who presented a skeleton robot with two DOF for elbow flexion/extension and
pronation/supination.
• Beside only the movements of the forearm, a certain approach can also be used for shoulder
movements
VESTS
All ideas require a stable connection between the human body and the part of the orthosis which delivers force
to the arm. To form a stable connection, some kind of a corset could be used. There are several corsets
available, for example the commonly used Boston brace, which is used for scoliosis correction.

F IGURE 41 B OSTON BRACE
Other corset‐like braces which are used are showed in figure 42.

F IGURE 42 T HORACIC L UMBO ‐S ACRAL ORTHOSIS ( LEFT ), C ERVICO ‐T HORACO ‐L UMBO ‐S ACRAL ORTHOSIS ( MIDDLE ) AND THE
J EWETT BRACE ( RIGHT )
Beside braces to support the back of a person, there are also upper arm prosthetics which are connected to the
trunk. An example is showed in figure 43.


F IGURE 43 U PPER ARM PROSTHESIS [18]
Children with DMD often have problems with their back and because they are not well able to move in their
wheelchair by themselves, pressure sores occur easily. According to discussions with an orthopaedic technician
of Roessingh Revalidatie Techniek and several ergo/physiotherapists, several points of attention concerning the
attachment to the body can be made:
• The load on the shoulder should be low; the scapulae move up during elevation of the arm and long
term pressure on the shoulder is unpleasant (similar to a backpack resting too much on the shoulders)
• The rest of load should be mainly on the iliac crest of the pelvic bone (similar as for a backpack)
• To minimize the chance of pressure sores, the amount of load on the iliac crest and the scapula can be
varied
• Minimize the load on the spine; DMD patients have a weak back and they often have already a certain
amount of scoliosis
• Use of breathing material to minimize the chance of covering the user in sweat

Observation of children with DMD during physiotherapy sessions at Roessingh rehabilitation centre, lead to
some more attraction points, see also figure 44. These are:
• The children were seating tightly in their wheelchair
• The muscles around the shoulder are weak and pressure on the scapulae cannot well be resisted
• The children are seated tightly to the backrest
• Scoliosis is often present
• Arm rest of some wheelchairs limit the available moving space
• Worktop of some wheelchairs limit the available moving space
• Different kinds of wheelchairs are used


June 30 BLE ARM SU
UPPORT]

F IGURE 44
4 D IFFERENT KINDS OF WHEE LCHAIRS
B. C ONCEPT S
Since balancing of thee arm is considered as imported, idea II,, III and VII arre selected an
nd worked ou
ut in more
detail. Off these three concepts, a m
model of LEGO
O has been made, see figurre 45. Finally, one concept is chosen
based on the advantagges and disadvvantages.

F IGURE 45
5 L EGO MODEEL OF THE CHOSEEN IDEA

C O N C E P T I

F IGURE 46 C ONCEPT I
Problems:
• Torsion
• Many parts
Advantage:
• All movements within the orthosis are in the same plane as the arm
• All movements of the arm are supported

C O N C E P T II

F IGURE 47 C ONCEPT II
Problems:
• Torsion
• Many different parts
• Movements limited
Advantage:
• Only support of the upper arm simplifies the construction

C O N C E P T III

F IGURE 48 C ONCEPT III
Problems:
• Interference with the human arm
• Shear stress between lower arm and cup
• Protruding parts
• Attachment points of springs
Advantage:
• Support of the arm at one point

CHOICE
To choose one concept, the sufficiency of the requirements is evaluated.
T ABLE 9 O VERVIEW OF THE REQUIREMENTS SUFFICIENCY FOR THE CONCEPTS
Requirement Concept I Concept II Concept III
No shear stress on skin 9 9 X
Free area around joints 9 9 9
Highly innervated areas avoided 9 9 9
No obstruction of respiration 9 9 9
Minimal friction within mechanism 9 9 9
Slight misalignment possible 9 9 X
Low unbalance between both sides of the body X X X
Control intuitive 9 X 9
Don and doff of device easy 9 9 9
Control manipulation of the hand in the region table 9 X 9
to head in a natural way.
Small dimensions 9 9 9
Placed close to body 9 9 X
Protruding parts and sharp edges avoided 9 9 X
Quiet operation of joints 9 9 9
Energy consumption low 9 9 9
Easy cleanable 9 9 9
Fulfil safety requirements 9 9 9
After comparing the three concepts, the 1st concept is chosen as best option. This choice is made since the 3rd
concept moves out of the arms plane during rotation of the arm and flexion of the forearm, with protruding
parts as result. This makes wearing underneath clothing impossible. The main disadvantage of the 2nd concept
is that the user is not able to move the hand in a natural way. The forearm is always in horizontal position. Due
to this, gravity has no influence on movements of the forearm and movements of the forearm are therefore
not supported by a spring. On the contrary, the user needs to flex the upper arm to bring the hand to the
mouth, since rotation of the upper arm is not supported in this solution. The movements of concept 1 since
movements are in the same plane as the arm, which is in line with development towards a device wearable
underneath clothing. Besides, as well upper arm as forearm movements are supported. This enables a person
to perform the movements in a natural manner. The requirement of unbalance between both sides of the body

is marked as unsatisfied, since the concept is only supporting the right arm. This could be put right by
implementation to both sides of the body. But there first will be focussed to one side to reduce the complexity.
The elbow mechanism is placed on the other side of the arm, which reduces the conspicuousness from the
outside. Furthermore, the alignment mechanism works better with this configuration, since it moves in similar
direction of the arm. When placed on the outer side of the arm, the mechanism should become longer, when
the forearm moves towards the upper arm.
C. P ROTOTYPE 1 – PROOF ‐ OF ‐ PRINCIPLE

For the first prototype, a diving vest is used to connect the orthosis with the body, see figure below. The bars of
the mechanism were made of steel which were connected with each other by U‐profiles of steel. Elastics were
used instead of springs since this was easier to adapt.

F IGURE 49 PHOTOS OF THE PROTOTYPE 1
E V A L U A T I O N : A N A L Y S I S O F R O M P R O T O T Y P E 1
The prototype is tested with two healthy male subjects with a similar posture. For the test, there has been
examined if the subject was able to make four of the movements described by van Andel et al.[10], as can be
seen in the figures below.

June 30 BLE ARM SU
UPPORT]
T ABLE 10 T EST RRESULTS OF PRO

OTOTYPE 1
Moveme
ent Critical points
• Resistance in ellbow mechan

nism when fle
exing the
bow Æ makess flexion difficult
elb
• Uppper arm cup mmoves towardds the shoulder during
ele
evation of the upper arm
• Resistance in ellbow mechan

nism makes itt difficult
to flex close to tthe mouth
• Hand falls from the wrist cup
• Hand to front head

h is possib
ble, back of the
t head
not Æ ROM foreearm flexion ttoo small
• Resistance in elb
bow mechanissm
• Up
pper arm cup m
moves during abduction
• Hand falls from

m wrist cup w
when reachingg to back
pocket

IMPROVEMENTS BASED ON THE TEST RESULTS
Based on the test results, five points of improvement are divined:
• Add bearings to eliminate shear stress between moving parts
• Adaptable bars to make it suitable for tests with several persons
• Add extra strap to avoid the forearm falls out the wrist cup
• Use a more stable corset
• Add extra rotation point above shoulder to make shoulder abduction possible
D. F INAL PROTOTYPE
The final prototype is made of aluminium elements as showed in the drawing below. The 5th point of
improvement is not implemented in the final prototype since this would made construction of the corset more
complex and time was limited. This point will be supplied in the future.
A
B
C
D

F IGURE 50 S OLID W ORKS DRAWING OF THE FINAL PROTOTYPE
TEST RESULTS
To evaluate the prototype, several tests are executed. The balance principle is tested by using weights. The
ROM is tested by one healthy subject and one person with Duchenne. Finally, two rehabilitation doctors gave
their opinion about the prototype and the expected use in daily life.
TEST WITH WEIGHTS
Since the springs used for the prototype were not ideal, balance of the upper arm and forearm was difficult. To
evaluate whether movement of the forearm has influence on the upper arm, a weight of 500g was hanged on
the forearm bar. The upper arm bar was placed in horizontal position by a weight scale, see figure 51.


F IGURE 51 T EST SETUP
The weight displaced on the scale is converted to a force. A vertical force of 14,23N was required to keep the
upper arm in position. To move the upper arm up or down, less then 0,1N was required. This has been tested
by slightly lifting the weighting device. The upper arm bar was moving up, however there was no response on
the scale of the weighting device visible. Moving the weight along distance a or a rotation φ did not change the
lifting force. Increasing the weight from 500g to 520g, resulted in a changed lifting force, it increased to 14,32N.
There can be concluded that forearm movements do not affect balancing the upper arm.
To measure the quality of the balance, a weight of 900g was hanged on the upper arm cup and a weight of
400g on the forearm cup. With help of a weight scale the required vertical force was calculated for several
angles. The results are in table 11. There can be seen that the system is not perfectly balanced yet.
T ABLE 11 T EST RESULTS OF THE FINAL PROTOTYPE

Angle forearm Vertical force Angle upper arm Vertical force
0 ‐ 30° ‐0,98N – 0N 10 ‐ 70° ‐2,94N – 0N
30 ‐ 90° 0N – 2,94N 70 ‐ 90° 0N ‐ 2,94N
90 ‐ 140° 2,94N – 9,81N
TEST WITH HEALTHY SUBJECT
To evaluate the range of motion of the device, the same test as used for prototype 1 is executed. After
assembling and attachment of the prototype to a corset, the distance between the shoulder and the elbow axis
of the mechanism seemed to be too large. The adjustable upper arm bars are shortened. Besides, the small
blocks in the alignment mechanism designed to avoid certain singularities, did have a negative effect on the
range of motion. During fitting for the first time, there was experienced that it was not possible to raise the
arm and therefore, the small blocks are removed.


[DESIGN OF A
T ABLE 12 T EST RRESULTS OF THE FINAL PROTOTYYPE

Moveme
ent Critical points
• Forearm flexion with rotated arm not posssible, due
to blocking elbow mechanismm
• Whhen upper arm m is rotated aand forearm is flexed,

meechanism lockks. Elevation of the uppe
er arm is
also not possiblee
• Up
pper arm supp
port not a righ
ht spot
• Whhen the forearm is flexed

d 90°, rotatio
on is not
possible
• Up
pper arm cann
not be elevateed <20°
• Abduction of thee arm not posssible
• No
ot enough fleexion of thee forearm, alignment
a
me
echanism bloccks

The main problem is the working of the alignment mechanism. Besides the field in which the elbow axis can be
moved, another problem was encountered. With an upper arm elevation angle of about 60 degrees, the
mechanism works quite well. At smaller angle, the bars of the mechanism are closer to each other. This
decreases the field in which the elbow axis can move, see figure 52. When the bars of the balance mechanism
are pressed on top of each other (for example when a person tries to rotate the arm more) and the upper arm
elevates, this results in unsmooth movement of the arm. Besides, when the bars of parallelogram 1 are on top
of each other and the user wants to rotate, the rotation axis of the mechanism moves down. However, the axis
of the elbow is moving towards the body instead of downwards.

F IGURE 52 ORIENTATION OF THE ALIGNMENT MECHANISM WITH UPPER ARM DOWN
During rotation, the elbow axis moves not only proximally (towards the body), it moves also laterally (away
from the midline of the body). This is not supported by the orthosis.
Furthermore, the rotation angle of the elbow joint of the mechanism is limited due to the shape of the
elements, see figure 53.

F IGURE 53 L IMITED ROTATION ANGLE ELBOW
The total range of motion in which the subject was able to move his arm, with use of his own muscle force will
be described in terms of the various arm movements described in appendix III. The range of humerus elevation
was 10 to 100°, the plane of elevation 50 ‐ 90°, pronation 0 ‐ 180°. The ranges of upper arm rotation and
forearm flexion are more difficult to describe, since these are dependent on the other angles. Rotation of the
upper arm is not possible when the humerus is elevated 90° in combination with forearm flexion of 90°. Flexion
of the forearm is about 70° when the humerus is elevated 90°, about 60° in case of humerus elevation of 10°
combined with humerus rotation of 0° (defined as forearm in front of the chest) and about 20° in case of
humerus elevation of 90° and humerus rotation of 0°.


T E S T W I T H DMD P A T I E N T
The prototype has been tested with two persons with a severe muscle loss. To reduce the costs, no new corsets
were made. To execute these tests, the mechanism was connected to a bar to put it beside the shoulder joint,
see figure 54.

F IGURE 54 T EST WITH A PERSON WITH DMD
The boys were asked to move their arm in several directions and to be as critical as possible in their response.
Several comments are made, based on observation of the movements and the given feedback.
• No support of the upper arm was experienced
• Forearm flexion was experienced as a little bit easier as normal
• Rotation difficult due to dimensions of the parts
• Movement not smooth, feels if arm accelerates at some spots Æ it was difficult to keep the bar exact
vertically
• The shoulder head moves a lot since the surrounding muscles are weak Æ alignment with shoulder
difficult
• The boys use a lot of compensation techniques to raise the upper arm
• The place of supporting the upper arm should be close to the elbow
• Corset too large
• Though it works not properly yet, both participants were enthusiastic about concept and would like to
test a new version.
EVALUATION OF REHABILITATION PHYSICIANS
The prototype is presented to two children rehabilitation physicians of two different rehabilitation centres.
Their comments are listed.


CORSET
• Wearing comfort is important.
• The dimensions of the prototype corset are too large
o Maybe a shoulder cap with bandages can be used, like for some prosthetics.
• No pressure on shoulder itself. The shoulder structures of people with DMD are so weak that it cannot
bear a lot of force
o Construction across shoulder to direct forces to thorax
• A person should be able to fit in the wheelchair chair chair while using the device.
o Some chairs are adaptable
ORTHOSIS
• The straps to support the upper arm and forearm are too small. This increases the chance of pinching
off the bloodstream
o Use cups like WILMER orthosis
• The dimensions are too large
• Avoid clothing damage. With current prototype, clothing can stuck between moving parts
o Leather caps to cover the orthosis
o Normal wear of clothing is probably insignificant
IMPROVEMENT OF THE FINAL PROTOTYPE
Based on the tests and evaluations, several recommendations for further development can be made.
CORSET
Recommendations to improve the corset are:
• Replace total corset by a brace across the shoulder resting on the thorax and a part in the flank. Use
straps to fasten it.
• Fixate shoulder to avoid undesirable movements of the shoulder head. The user should keep the
possibility to use its compensation techniques to move the upper arm
MECHANISM
Recommendations to improve the mechanism are:
• Use of other material (for example carbon elements)
• Reduce dimensions of the parts
• Change the orientation of the alignment mechanism, so the elbow axis can move freely also when the
upper arm hangs alongside the body (figure 55).


F IGURE 55 A LTERNATIVE ORIENTATIONS OF ALIGNMENT MECHANISM
• Make rotation of the upper arm possible when the forearm is flexed 90°
• Increase rotation angle of the elbow
• Add extra rotation point above shoulder
• Use larger arm cups

F IGURE 56 W IDER ARM CUP
• Use stronger springs
• Add caps to cover the orthosis to avoid clothing damage

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According to Grootenhuis et al [6], who F IGURE 1 MAN USING

investigated the quality of life experienced by THE A RMON [1]

people with a severe muscle disease, the

F IGURE 2 GIRL WITH In literature, one passive wearable arm support, the WREX[2], was found,

The main n problem meentioned in otther orthosis is misalignme ent between tthe elbow join nt and the me echanism.

To reducee visibility, the part of the orthosis alonggside the fore earm is on thee inner side off the arm. Thiis position

Besides further improvement of the non‐powered orthosis, actuation

The main n problems in daily life of cchildren with DMD have a ssocial charactter[6]. It is asssumed that th he arsenal

When a d device is not vvisible from the outside, it is reasonable e to assume tthat a person is willing to u

The devicce is based onn the notion that not the co omplete masss of the user’ss arm needs to o be carried in order to

D ISCU SSION AN D CONCLU

T ABLE 1 O VERVIEW OF THE PRESENTTED DEVICES

III. A RM KINEMATICS / DYNAMICS

T ABLE 2 M EAN RESULTS OF TOTAL ROM DURING SEVERAL DAILY ACTIVITIES

Humerus elevation 10±5˚ to 135±9˚

Humerus rotation ‐89±13˚ to 60±9˚

Elbow flexion 0±5˚ to 143±5˚

Forearm pronation** 35±20˚ to 161±16˚

T ABLE 3 M EAN RESULTS OF THE ROM TO MOVE THE HAND TO THE MOUTH

Humerus elevation 20±5˚ to 65±10˚

Humerus plane of elevation* 60˚ to 80˚

Humerus rotation ‐35±25˚ to ‐65±5˚

Elbow flexion 45±10˚ to 124±1˚

Forearm pronation** 90±10˚ to 120±10˚

Ai = Root z ,θi Transz ,di Transx , ai Root z ,α i

T ABLE 4 D ENAVIT ‐H ARTENBERG PARAMETERS

3 0 ‐Lhumerus 90˚ Θ3 = rotation

5 0 ‐Lforearm 0˚ Θ5 = pronation

6 0 ‐Lhand 0˚ Θ6 = ‐

T ABLE 5 M= BODYMASS , H= BODYLENGTH , L= SEGMENTLENGTH

Trunk 0.497*M 0.288*H 0.500 * L

Clavicle N/A 0.129*H N/A

Upper arm 0.028*M 0.188*H 0.436 * L

Forearm 0.016*M 0.145*H 0.430 * L

Hand 0.006*M 0.108*H 0.506 * L

Humerus plane of elevation 0 Nm 0 Nm 0 Nm

Humerus elevation (up/down) ‐9.5 to ‐2.9 Nm ‐13 to 0.1 Nm ‐14.7 to 1.1 Nm

Humerus rotation 1.9 to 2.7 Nm ‐0.5 to 4.0 Nm 0 to ‐1.3 Nm

Elbow flexion ‐4.3 to 0.8 Nm ‐4.7 to 3.1 Nm ‐4.6 to 1.7 Nm

Forearm pronation 0 Nm 0 Nm 0 Nm

Vtot = Vmass + Vspring

B IOMEECHANICA L MODEL OF THE F INAL CON CEPT

When F f ⋅ r f ⋅ sin α = F1 ⋅ r1 thee sum of the m

by use of the potential

V pot = E pot , F1 + E poot , F1 + E pot ,veeer = constannt

The forcee delivered byy a spring is givven by k ⋅ Δ L . In this situaation Δ L can

∑ M = −F u ⋅ ru ⋅ siin γ + F3 ⋅ r3 − Felbow ⋅ l ⋅ sin

V pot = E pot , F3 + E pot ,veer = constant

The force delivered by a spring is given by k ⋅ Δ L . In this situation Δ L can be calculated by:

mf 1.12 kg mu 1.96 kg

rf 0.11 m ru 0.14 m

s 0.19 m r3 0.16 m

r1 0.15 m c 0.04 m

T ABLE 8 R EQUIRED RANGE OF MOTION ( SEE A PPENDIX 3)

Humerus elevation 20±5 to 65±10 10±5 to 135±9

Humerus plane of elevation 60 to 80 0 to 100

Humerus rotation ‐35±25 to ‐65±5 ‐89±13 to 60±9

Trunk 0.497M 0.288H 0.500 * L

Upper arm 0.028M 0.188H 0.436 * L

Forearm 0.016M 0.145H 0.430 * L

Hand 0.006M 0.108H 0.506 * L