2009 IEEE 11th International Conference on Rehabilitation Robotics
Kyoto International Conference Center, Japan, June 23-26, 2009
Design of a Flexible Fluidic Actuation System for a Hybrid Elbow
Orthosis
C. Pylatiuk, A. Kargov, I. Gaiser, T. Werner, S. Schulz, and G. Bretthauer, Member of IEEE
Abstract— In this article the design of a new upper limb
rehabilitation system will be presented. A lightweight, modular,
and portable system is achieved by the combination of
electromyographic (EMG) control, functional electrical
stimulation (FES), and the use of miniaturized flexible fluidic
actuators (FFA) integrated in an elbow orthosis. First, the state
of the art of upper limb rehabilitation devices will be discussed
and requirements extracted. Then, the design concept of the
new prototype upper limb training system will be presented.
Subsequently, a miniaturized fluidically driven actuation
system, including its mechatronical components, will be
highlighted. Finally, an overview of the performance and
function will be given.
I. INTRODUCTION
P ATIENTS with paraplegia of their upper extremities due
to accidents, diseases or disorders of the central or
peripheral nervous system usually suffer from
limitations of their independence and quality of life. Loss of
motoric functions and in particular of the gripping function
leads to life-long dependence on helping persons. The
objective of modern rehabilitation medicine is to at least
partly restore the individual functional deficiencies. Major
options for functional improvement are physiotherapy [1]
and surgical interventions [2]. Another option is functional
electrical stimulation (FES) [3]. All FES systems for
restoring the gripping function may only be used
successfully, if the shoulder and elbow are functioning
correctly, as patients have to possess sufficient residual
functions to place the hand independently in space.
However, most tetraplegic patients in Europe have a lesion
of the spinal cord at the level of C4 or higher with functional
restrictions of the elbows and sometimes also of the
shoulders, according to data taken from the European
Multicenter-Study of Spinal Cord Injury (www.emsci.org).
So far, only few working groups have studied the problem
of restoring the function of the elbow and shoulder: [4] used
an extended free-hand system to restore the typically lacking
elbow straightening of sub-C5 paralyzed patients. In contrast
to this, [5] used a system with intramuscular, percutaneous
electrodes to restore the shoulder function in hemiplegic and
I. Manuscript received February 6, 2009. This work was supported by
the Federal Ministry of Education and Research (BMBF) within the funding
program “Innovative aids”. The project “Orthojacket” is a health research
cooperation between science and industry.
C. Pylatiuk, A. Kargov, I. Gaiser, T. Werner, S. Schulz, and G.
Bretthauer are with the Institute for Applied Computer Science,
Forschungszentrum Karlsruhe, Hermann-von-Helmholtz-Platz-1, D-76344
Eggenstein-Leopoldshafen, GERMANY (corresponding author’s phone:
+49-7247-82-2430; fax: +49 7247 82 5786; e-mail: pylatiuk@iai.fzk.de).
9781-4244-3789-4/09/$25.00 ©2009 IEEE
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tetraplegic patients. Both systems are exclusive FES
systems, i.e. suitable muscle groups are stimulated not only
for generating motion, but also for maintaining a static joint
position. Due to the weight of the upper extremity and non-
physiological, synchronous activation of nerve endings
when applying external electric pulses, rapid muscle fatigue
occurs, which largely limits the principle usability of such
systems in routine clinical use. Consequently, FES can be
applied to restore palmar and lateral prehension in patients
with high level paraplegia successfully, but not to restore
elbow and shoulder function. Today, an early, target-
oriented, function-specific training of high intensity is
performed to restore the function to a certain extent by
enhancing neuroplasticity on the spinal and supraspinal
levels. First approaches to applying this intensive movement
training also with the help of training machines shall be
presented and discussed below.
II. STATE OF THE ART ANALYSIS
Up to day, many prototypes of upper limb active training
systems have been constructed using different actuation
systems, including both electric motors and fluidic actuators.
According to [6], two different classes of robotic aids can be
distinguished: Stationary therapeutic systems that are mainly
used in a clinical environment and home-use systems that
assist in activities of daily living.
The use of floor-mounted robotic systems [6-9] has proved
to have a positive effect as an additional option for
rehabilitation therapy e.g. after stroke. However, their use is
limited to the hospital due to their size and complexity. An
overview of different rehabilitation robots is given in [6].
Training systems for the upper extremity, which may also be
used at home, typically are driven by DC motors with a high
torque-to-weight ratio for support of the intended arm
motions. A prototype of a wearable powered elbow orthosis
for orthopaedic rehabilitation was presented in [10]. Like the
exoskeleton for the rehabilitation of forearm pronation and
supination presented in [11] both systems are driven by a
combination of DC motors and series elastic actuators that
allow for compliance of the actuation mechanism and
softness of some abrupt torque inputs from the user. The
latter was designed to extend the therapy of wrist rotation by
performing rotations and tracking of the wrist, while
completing virtual task routines. Additionally, therapeutic
levels of resistance can be programmed. Other wearable
active orthosis systems and exoskeletons were designed to
suppress upper-limb tremor while allowing natural
movements [12] or for daily forearm motion assistance [13].
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 One of the first active orthesis driven by a pneumatic
actuator was developed in the 1950s [14]. It is actuated by
so-called “McKibben” artificial muscles that consist of a
braided material, a gastight inner tube, and end fixtures for
external attachment and pressurization. When pressurized
with compressed CO2, the braided material expands and the
axial length contracts, thus exerting tension (=contraction
principle). In the 1970s, these systems were inferior to DC
motor-driven actuators that were more compact. Pneumatic
muscle actuators were used again in 1984 with the
availability of the 'Rubbertuator' pneumatic muscle actuator
[15] and other pneumatic artificial muscles [16, 17]. So far
there are no wearable powered elbow orthoses commercially
available.

III. DESIGN REQUIREMENTS Fig. 1. Schematic representation of the upper limb training system
driven by a fluidic actuation system: m1, m2= myoelectrodes; v1-v4=
From the short overview of different arm rehabilitation valves; p1, p2= pressure sensors; a1, a2 – joint positioning sensors; P
systems, requirements relating to the design and – hydraulic pump; FES – functional electric stimulation, thin lines =
electric wires, thick connecting leads = fluid pressure lines.
functionality of a powered upper limb training system can be
derived. It should be non-invasive, portable to be applicable
at home, and it should have lightweight, compact The FES system for control of hand grasping will be
components of ergonomical and modular design, allowing added in the next prototype and is described in [21,22]. In a
for simple, effective, and safe use of the training system first step a prototype has been developed that consists of a
during rehabilitation therapy. lightweight elbow orthosis made of two reinforced half-
The moments exerted at the elbow joint by exclusive FES shells with Velcro® fastener for fixation and is driven by an
systems are limited [18]. In order to achieve higher moments fluidic actuation system controlled by EMG signals. The
and static forces to overcome gravity and to regain powered orthosis is displayed in Fig. 2.
independence of helping persons, additional power is
needed. Thus, the combination of both FES to restore and A. Fluid Actuation System
regulate neuromuscular grasping function and artificial A lightweight, modular miniature fluidic actuation system
muscles to excert the force and the range of motion and to was designed to fit into a wearable elbow rehabilitation
maintain the position of the extremity against gravity
overcomes limitations of existing rehabilitation systems.
According to the findings presented in [18], elbow joint
moments of 3.1 Nm are needed to hold an average forearm
against gravity at an angle of 90 degrees. Additionally,
maximum elbow joint moments of 5.8 Nm and a range of
motion from 16 to 165 degrees were evaluated when
performing activities of daily living [19]. However, a
functional range of elbow motion between 30° and 130° was
recommended [20]. As a consequence, an elbow training
system should allow for this range of elbow joint motion
with moments higher than 6 Nm.
Finally, safety is an issue of utmost importance when Fig. 2. Components of a fluidically driven elbow training system
designing a rehabilitation device, especially for patients with prototype. A= flexible actuator, M=microcontroller and drivers,
paraplegia. V=valves, B=Battery, S= pressure sensors.

IV. ACTIVE ORTHOSIS PROTOTYPE orthosis. The fluidic actuation system comprises
components, such as a custom-made hydraulic pump,
An elbow joint training system was developed as part of a
miniature valves, and custom-made flexible fluidic actuators
modular hybrid upper limb rehabilitation system that is
(FFA). They are depicted in Fig. 3.
illustrated schematically in Fig. 1. It will comprise three
modules:
1) a functional electric stimulation system,
2) a fluidic actuation system, and
3) a controller using biosignals from surface EMG.

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Fig. 3. Components of the miniature fluidic actuation system: left:
flexible fluidic actuator, middle: hydraulic pump, right: valve.
Each of the two FFAs consists of reinforced flexible
bellows that expand during pressurization, contrary to the
McKibben muscles that shortens (contraction principle).
When integrated in the levers of a joint, a rotational
movement can be achieved, like illustrated in Fig. 4.
Fig. 4. Expansion principle of the FFA-joint used in the powered
elbow orthosis. Upper: deflated FFA, lower: pressurized FFA in a 90°
position.
A more detailed description, including a mathematical
model to calculate the resulting forces of FFA, is given in
[23]. The dimension of each actuator is 20 mm in diameter
and the maximum torque is 3 Nm (Fig. 5), which is
determined to be sufficient for a functional support of the
patient’s elbow, when two actuators are combined, thus
working in parallel.
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3.0
2.5
3 bar
6 bar
joint moment [Nm]
2.0 9 bar
1.5
1.0
0.5
0.0
0 10 20 30 40 50 60 70 80 90
flexion angle [°]
Fig. 5. Torque characteristic of a single FFA at 3, 6 and 9 bar
pressure.
The FAA are characterised by inherent compliance which
provides both, safety and comfort compared to conventional
stiff actuators [24]. The actuators may be driven either
hydraulically or pneumatically. In the prototype presented a
hydraulic miniature custom-made pump is used to drive the
actuators and obtain an autonomous system. The dimension
of the pump is 21 x 42 mm and it combines the best ratings
in performance regarding efficiency, power by weight, two-
way operation, and simple, but robust design. It allows for
elbow flexion within two seconds.
Control of the pressurized liquid is achieved via miniature
3/2-way monostable valves (type picosol from FAS,
Switzerland). The valves allow for both hydraulic and
pneumatic operation. In a hydraulic system only one valve
per actuator is needed (v1 and v2 in Fig. 1), because
pressurization and deflation are controlled by the same
valve. Hence, inlet and outlet are identical. In a pneumatic
system the flow rate is much higher, so that a single valve
can provide both actuators with pressurized air. However,
one valve is needed to control the actuator’s inlet for
pressurization (v1 or v2 in Fig. 1) and another valve (v3 or
v4 in Fig. 1) to open the actuator for deflation.
B. Mechatronical Components
Compact mechatronical components are also housed in
the training system to control the fluidic actuation system.
They consist of a controller board, including driver
electronics, for the valves and the pump, pressure and
positioning sensors, EMG surface electrodes, and a battery
and are illustrated in Fig. 6.
The circuit board comprises a programmable controller
(type PIC16F877 by Microchip Technology Inc., USA) with
analog and digital inputs for the sensors, an A/D converter,
and drivers for the valves and the gear pump. Additionally, a
wireless Bluetooth™ interface is integrated in the circuit
board that allows for changing the settings of the controller.
Electric power is provided by a lithium battery.

Fig. 6. Mechatronical components used in the elbow training system.
C= controller including drivers, S= pressure sensors, P= positioning
sensors, E= EMG surface electrode; B= Battery.
C. Design and Function of the Prototype
The design of the first prototype is illustrated in Fig. 7.
On each side of the orthosis, a flexible fluidic actuator is
mounted axially with the rotation point of the orthosis.
Surface EMG electrodes are placed on the bulges of the
biceps and triceps muscle to control elbow flexion and
extension. All components are covered and protected by
thermoplastic casings with rounded edges. The overall
weight of the training system, including all components, is
700 grams, with the brace accounting for 500 grams. The
low weight reduces the mass to be moved and ensures
wearability.
Fig. 7. First prototype of the active elbow training system.
The control unit is responsible for the analysis of control
signals from the surface EMG electrodes depending on the
input from the position and pressure sensors, thus enabling
e.g. proportional control of elbow flexion by fluidic
actuators. The powered orthosis can be used in different
applications of rehabilitation. Firstly, it can operate like a
continuous passive motion machine (CPM) by inducing all
the power needed for moving an elbow in a given range of
movement. Thus external power is used to maintain mobility
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of the elbow joint. Furthermore it can assist the patient`s
movements within any specified degree.
In a next step the functional electric stimulation system
will be integrated and a higher level of control is under
development to coordinate the movements of the elbow
joint, the wrist and hand grasping to perform activities of
daily living.
A modification of the first prototype was designed in
CAD by adding a second FFA on each side of the elbow
joint that works antipodal resulting in an active extension
movement of the elbow (Fig. 8).
Fig. 8. Modified powered orthosis with two FFA on each side of the
elbow joint to enable both powered flexion and extension of the
elbow.
V. DISCUSSION AND CONCLUSION
People with paraplegia, who suffer from limited voluntary
control of the triceps and biceps, typically have deficiencies
in the power, speed and accuracy of elbow movements. In
addition, the reachable workspace is reduced. It has already
been demonstrated that these deficiencies can be corrected
by the addition of external torque at the elbow using a
powered orthosis [10, 17, 25] or exoskeletons [9, 11, 12].
A new elbow training system is presented for patients
suffering from paraplegia, which will combine both FES and
additional external force generated by flexible fluidic
actuators. Safety is ensured by inherent compliance of the
actuators, by mechanical stops and by a limited moments
that can be applied to the upper limb. The prototype of an
elbow flexion orthosis presented is part of a modular system
to be developed that will also include adjacent upper limb
joints, such as shoulder and wrist. The aim of the project
was to design an portable upper limb training device that
meets the requirements of being lightweight, compact, and
inexpensive. However, further investigation and clinical
evaluation of the device are needed to further improve the
system.
Based on the specifications given in [18, 19], moments of
3.1 Nm are required to hold an average forearm against
gravity and a maximum of 5.8 Nm are exerted during
activities of daily living. The system presented is designed to
provide elbow flexion moments of up to 6.5 Nm that enable
the patient to lift an extra load like a glass of water with the
impaired extremity.
 Hydraulic operation of the training system allows for Robotics (ICORR 2001), Strasbourg, France, pp. 24-30, April 25-27,
2001.
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