Department of Education, National Institute of Handicapped Research

146 DEPT of EDUCATION, NATIONAL INSTITUTE of HANDICAPPED RESEARCH, DIVISION OF REHABILITATION ENGINEERING

Joseph E . Traub, Division Director

Rehabilitation Engineering Center comprehensive rehabilitation pro- Tufts-New England Medical Center gram in New England . The 25-bed inpatient unit and the larger outpa- Biomedical Engineering Center—Box 1009 tient unit serve both children and 171 Harrison Avenue, Boston, Massachusetts 02111 adults from a wide geographical Richard A. Foulds, M .S ., Director area. The staff of the Institute are members of the University Depart- ment of Rehabilitation Medicine. Rehabilitation Engineering at Tufts-New England yWediou! Center is con- The Biomedical Engineering Center ducted through the 8iunnedicm! Engineering Center . This program ivadmin- iotrutivo!y part of the Department of Rehabilitation Medicine and has very The laboratories and offices of the close ties to the Department of Engineering Design . If one were to be a pur- Center occupy approximately 4000 ist, the term "engineering" in the title of this program would be only par- square feet in the Medical Center tially correct. The activities of our Center, and even the make-up of our staff, complex. Facilities include electron- represent a conceptually broader approach than the traditional definition of ics and mechanical prototype labo- engineering. ratories. (The mechanical laboratory is equipped with a 4' x 4' The center's long-time role in and Training Center (RT-7) and the vacuum forming table .) The Center evaluation of new rehabilitation de- Rehabilitation Engineering Center also has a computer laboratory in vices that might improve the quality grant awards. Numerous engineer- which resides a PDP11/20 minicom- of patient care (and the efficiency of ing development projects are funded puter . Unique to the computer facil- service delivery) is well-known . We through governmental and private ity are a voice synthesizer and a will continue these missions as the contract. Training in Rehabilitation three-dimensional ultrasonic digi- VA Rehabilitation Engineering Cen- Engineering is a growing activity, tizer. ter. But it should be apparent from with courses being developed for The Client Service component op- past and current efforts that, al- both academic curricula and inser- erates a clinical evaluation room in though the major programs are vice/continuing education . The de- which the workstation evaluation service delivery and evaluation of livery of technical services for the system is based, as well as a num- devices for the handicapped in sup- severely disabled is an ongoing ber of commercial devices available port of treatment programs, the clinical activity which is supported for demonstration. center also has certain unique ca- by direct fee-for-service charges. RESEARCH pabilities in research. The following briefly describes the In addition to what we would like setting in which Rehabilitation En- The following is an overview of to consider to be an excellent engi- gineering is conducted at Tufts, and the Research Activities conducted neering staff, we also have drawn outlines the range of activities of by the Biomedical Engineering Cen- to our effort highly skilled individu- the program. ter. While the primary thrust is in als with backgrounds in uooupa- the area of Nonvocal Communica- donul therapy, !inQuiotiou, biology, Tufts-New England Medical Center tion, related areas of investigation chemistry, and psychology . This The complex of facilities known are also often included in the pro- year we have been fortunate to gain as Tufts-New England K8edioa! Cen- gram. the services of Mr . James Viggiano, ter is an outgrowth of a long rela- a non-vocal consumer . He brings tionship between two autonomous Electronically Aided Communica- with him years of life's experiences organizations : Tufts University and tion for the Severely Physically that will be invaluable in our New England N4edioa! Center Hos- Disabled Nonvocal research . It is our feeling that this pital . The W4odium! Center occupies Funding So-rce : Rehabilitation collection of people represents a 13 acres in downtown Boston and Services Administration (NIHR). creative problem-solving team that consists of the teaching and re- Status : Completed is capable of investigating toohnu- search facilities of the Tufts Univer- Richard Foulds, Principal Invastiga- !ogiool solutions that are appropri- sity Schools of Medicine, Dental tor ate for human problems. Medicine, and Occupational Ther- Support for the program is drawn apy, and the 452 bed New England Thinpnjeo dealt with the inves- from ovvido range of sources . Fed- Medical Center Hospital. tigation of the communication diffi- erally funded research sponsored by culties of nonvocal cerebral-palsied the National Institute of Handi- The Rehabilitation Institute individuals. The project has re- capped Research (NIHR) represents Rehabilitation Services at Tufts- sulted in the engineering develop- a oubotaniiul portion of the activi- New England Medical Center are ment of three electronic devices . The ties. This funding is provided provided through 1hmTufts Rehabil- Tufts Interactive Communicator (TIC) through the Rehabilitation Research itation Institute . This was the first is a single-key scanning device 147 Bulletin of Prosthetics Research, ~~~~4 (Vol . 17 No. 2) Fall 1980

which allows the user to select al- Auditory Feedback as it Relates to Development of a Functional Eye phabetic characters with a mini- Language Acquisition and Utili- Movement Communication Sys- mum of phyaival movement. Char- zation tem acters are seen on a small video Funding Source: RSA . Status : Com- Funding Source : RSA/NAHR (Na- monitor as well as a paper strip. pleted tional Institute on Handicapped The Symbol TIC is another device, Richard Foulds, Principal 0numstUga- Research) . Status : Continuing similar to the TIC . It provides sin- tor Randall Fincke and Richard Foulds, gle-switch selection of symbols and Principal Investigators pictures for the user who is unable Thenonvnoa! individual with nor- to spell. mal receptive language skills ex- It has been observed that, in gen- The Tactile TIC provides a !ap- hibits a wide gap between his re- eral, users of nonvooal communi- board*bodevixevvith o touch-sen- ceptive understanding of spoken cation systems make eye contact sitive keyboard which can be cus- English and his ability to express with their desired character or mes- tomized to meet the user's English using a typewriter or other sage at some time prior to the ac- motion, accuracy of movement, and assistive device . This is felt to be tual selection of that message . This language ability . Output is made via partially caused by the somewhat is due to the ability of that person a 32 character light emitting diode peculiar rules of spelling required to make rapid coordinated motor (LED} diop!oy . The ^SymT!C" e in English. movements that would allow for the "TacTIC" are both portable and bat- This project intended to demon- design of a fast direct-selection de- tery-operated. strate the user's ability to make use vice. of auditory reception skills in This project intends to monitor Computer-Aided Motor Communi- "sounding out" words using a corneal reflection as a means ofde- cation for the Severely Disabled scanning device and a voice syn- termining the orientation of the eye Nonvocal thesizer . A modified SymT!C was within the head . The orientation of Funding Source: RSA. Status : Com- used in conjunction with a Votrax the head is to be monitored by an pleted VS6.4 synthesizer to present the ultrasonic ranging system which will William Crochetiere, Principal In- phonemic alphabet of the Goldman- respond to three head-mounted vestigator Lynch sounds and symbol set and transmitters . The combination of were evaluated for their abilities to data from these sources can be used The use of scanning as a means use auditory and visual (printed to define mathematically the line of of selecting characters on a com- symbol), and visual-alone methods sight of the individual . This system munication device is an inherently of feedback . The former was shown can, potentially, be used for a very slow means of expression . The lim- to be superior. flexible and rapid means of select- itations of the TIC or similar devices ing messages and characters . Ex- are due to the time required to offer Clinical Implementation of Auditory periments have shown that the two the entire repertoire of characters in Feedback monitoring techniques will provide a predetermined sequence . This Funding Source: Massachusetts De- sufficient accuracy . Subsequent project has successfully shown that partment of Education . Status: work will include a demonstration access time can be appreciably Proposed and evaluation of a communication shortened (30 to 50 percent) if the Richard Foulds, Principal Investiga- system. device modifies its scanning to tor present those characters which are Application of Low Cost statistically most likely to follow The equipment used in the pre- Microcomputer Systems for those that have already been typed. ceding project was not capable of Communication Aids A prototype unit has been fabri- leaving the laboratory and follow- Funding Source : RSAINIHR. cated which examines the three ing the subjects back into the class- Status : Continuing previously typed characters and di- room . This proposal requests fund- Andrew Thomas, Principal rectly offers the character which ing for the modification of a Radio Investigator (according to the statistics of the Shack TRS-80 microcomputer with English language) is most likely to voice synthesizer . This modified unit The availability of microcomputer follow. The user can select that will replace expensive hardware and technology has made tremendous character with a single switch clo- will be placed at the Massachusetts changes in the approaches taken in sure . The unit offers two such Hospital School . The Auditory Feed- developing communication "likely" characters before returning back Project will continue at that systems . The Tufts Interactive Com- to a normal scanning procedure. school. municator will be totally rodo There is a 50 percent likelihood that oignod' using an RCA 1802 micro- the first character offered will be computer . A number of interesting correct. features made possible by comput- 148 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

ing power will be explored . Addi- Range and Controllability of Development of a Nondistorting tional effort will be placed in the in- Physiological Output Signals in Transducer System for vestigation of graphics capabilities People with Cerebral Palsy: A Measuring Pressure at the of microcomputers as a means of Systematic Evaluation Procedure Tissue-Cushion Interface displaying oymbnl sets (Bliss, Re- for Interface Selection Funding Source : RSAINIHR. bus, Funding Source : RSAlNIHR. Status : Continuing Status : Continuing James O'Leary, Principal Design of an Audio Message Earl Gaddis, Principal Investigator Investigator System Funding Source : RSAINIHR. The purpose of this project is to The objective of this project is to Status : Continuing develop a systematic procedure for design and build an instrument Andrew Thomas, Principal identifying the fu!l range of phyein- which will accurately determine the Investigator !ogioal output signals that a se- pressure distribution under a seated verely physically disabled person is or reclining patient . The transducer The use of auditory output from capable of producing, and deter- will be useful in evaluating equip- a communication aid is required in mining how accurately and effec- ment for use by an individual pa- certain teaching situations . This tively he or she can actually control tient, and as a research tool in the could be provided by a voice syn- each of those signals . Identification area of evaluating various seating thesizer, but would then have the and assessment of proportional, or and cushioning systems. limitations of artificial speech. analog, output modes vvil be em- This project has developed eRan- phasized . The completed procedure Dynamics of Communication with dom Access Tape Recorder which will be carried out on a number of the Nonvocal can quickly access a prerecorded subjects with cerebral palsy, and the Funding Source : RSAINIHR. Status: message. The messages are stored results will be evaluated in terms of Continuing on standard cassette tapes by the implications for interface design and Cheryl Goodenough-Trepagnier, clinician or teacher, allowing for to- selection. Biofeedback techniques Principal Investigator tal customization of the output . Se- and short-term learning factors will lection ufo message is made via a be explored to a limited extent. The objectives of this project are: modified interface such as the Sym- to observe and characterize the bol TIC . Presently 56 messages can Research in Posture and Support communication interaction probe stored . Addidonol message lo- Orthoses duced by nonvocal people with oth- cations will shortly be made acces- Funding Source : RSA/NkHR. ers in their environment ; to record sible. Status : Continuing by means of questionnaires attitu- dinal factors which result from and Randall Fincke, Principal Development, Testing, and act upon communication effective- Investigator Application of a Phonologically- ness—the nonvocal person's self Based Communication System The project has as its principal esteem and the attitudes and judg- for the Nonvocal objective the development of a ments of others about his abilities. Funding Source : RSAINIHR. seating procedure which minimizes Evaluation of a Commercial Speech Status : Continuing the cost of fitting and fabrication, Recognition Device as an Aid to Cheryl Goodenough-Trepagnier, while maximizing the benefit to the the Motorically Disabled Principal Investigator client. Much of the attention has Funding Source : RSA/NIHR. Status: been given to the use of Thermo- Continuing The objective of this project is the forming ABS ' foam ' and a covering development and testing of an effi- rnetoriul as a technique for produc- William Crochetiere, Principal cient and fully productive commu- ing a customized wheelchair insert. Investigator nication system . To this end the Another area of intense effort is in The purpose of this project is to project is examining changing the the fabrication of a cast which re- explore the usefulness of a small linguistic component used in cur- tains the proper body contours while and inexpensive speech-recognition rent communication devices from allowing the client to leave the clin- device that is currently marketed. letters to larger chunks of words, ical setting . This is important for This device will be studied to deter- either syllables or non-syllabic pho- convenience and safety . Other areas mine its reliability for distinguish- neme sequences. This work is based of investigation will include foaming among the spoken digits, and upon previous research by the ing techniques . the international alphabet (alpha, investigator in Quebec which has bravo . . .) . Success in this project resulted in the communication sys- will lead to additional study of the tem known as "Par le si la b ." recognition of sounds made by dysarthric individuals . 149 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

Investigation of a Transition Pre- 2. To develop an employment pro- aUovvu particular client tnfuno- serving, Diphone Method of file consisting of pntential jobs tion independently in each de- Speech Synthesis (as determined by the test result scribed job; Funding Source : National Science and client interests, and match- 3. To investigate potential sources Foundation . Status : Proposed ing these to potential jobs by us- of employment; and Richard Foulds, Principal ing the D .O.T. and Worker Train 4. To place clientele in goinful em- Investigator Group Guide) and an outline of ployment through the fabrication workstation designs needed to of modified workstations. The state-of-the-art voice synthe- sizers available as aids for the phys- Contracts for Development and Research ically disabled are such that the The Bionnudiva! Engineering Center often is called upon to provide engi- voices sound mechanical and ro- neering input into projects which relate to industry, state agencies and in- botic . This is due to the concatena- dividuals . These differ from research projects in that the contracts often tion of phonemes to produce words. carry specifications which relate to the type of data required, or the function In such stringing together, the coar- of the individual device . The projects which follow give examples of the ticulation which would exist in natural speech is not evident . It has range of work involved . Many individual designs are carried out under the been shown that, in natural speech, client service section and will be discussed later . the boundary between phonemes (the acoustical effect that one phoneme has on the next) is consider- Evaluation of the Pressure Distri- Design mYm Multiple Switch Input a bly more important than the bution Capabilities of Commercial Audio Response Communication acoustical information in the nu- Mattresses System cleus of the phoneme itself . This Funding Source : The Continental Funding Source : Lorraine County project intends to examine the ex- Company . Status : Continuing Board of Mental Retardation. Sta- tent to which phonemic units taken James O'Leary, Principal tus: Continuing from natural speech, and consisting Investigator Jonathan Bretz, Principal Investi- of phoneme-to-phoneme bounda- gator ries, can be used as the elements of The distribution of pressure has speech synthesis. long been considered, by rehabili- The Random Access Tape Re- tation engineers, as being of prime corder developed by the Center is concern in the prevention of ulcer- to be attached to a !aptruyoontoin- ations. The distribution of pressure ing a number of independent Vocational Interface : A Project in on an individual while lying in bed switches which can be used to di- Job Modification for the Severely is also of concern in evaluating the rectly select pre-recorded mes- Disabled subjective concept of comfort . The sages. The agency has specified the parameters for the design as they Funding Source : Massachusetts Re- Center has contracted to perform a number of tests which measure the relate to their clientele. habilitation Commission . Status: Continuing pressure distribution provided by a number of commercial mattresses Design of a Communication System Jonathon Bretz, Principal which vary according to manufac- and Wheelchair Control to Meet Investigator turer and basic design. the Needs of a Nonvocal High School Student The purpose of this project is to Funding Source: Massachusetts Re- develop expertise in all facets of Design of an Encoded Communica- tion Device habilitation Commission. Status: workstation evaluation, design, and Funding Source Continuing fabrication for the non-college- : Individual Family. bound severely physically disabled; Status : Completed Jonathan Bretz and Richard Foulds, and to incorporate this service into Richard Foulds, Principal Investiga- Principal Investigators the existing fee-for-service Rehabil- tor itation Engineering Client Service The specific case of a severely Program at the Biomedical Engi- A custom communication devic.e disabled high school student has neering Center. requiring only a single switch input been studied and a design for a Specific objectives are: was designed and fabricated for an wheelchair control, communication 1 . To develop an evaluation test individual. The basic concept was device, and customized insert has center to determine selected supplied by the individual and his boonmproved. family . clients' functional abilities in ma- nipulating common interfaces found in industrial settings; 150 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

Design of a Workstation for a Se- CLIENT SERVICE verely Disabled Computer Test Technician The outgrowth of our Rehabilitation Engineering Research Program is the Funding Source : Digital Equipment desire the in aid- Corporation and the Massachu- ing the clients within the New England states. setts Rehabilitation Commission. uurumruS*rv/ooenonnuoononadministratively separated from the re- Status : Completed search nnmpononta!thoughit shares both staff and laboratories . The formal Randall Fincke, Principal Investiga- effort began in 1975 with an Innovation and Expansion Grant from the Mas- tor sachusetts Rehabilitation Commission . This three-year award enabled the Center to recruit and train personnel, and to build experience in the delivery An individual with a progressive of service. nouro!ogioul disorder has been re- turned to work through use of a to- Following the grant period, the broadened the scope of the client tally personalized workstation . The staff worked with the Commission service activities. design allows him to easily insert staff in the creation of a clinical rate At the present time the Center the circuit cards to be tested . Spe- structure which was approved by services the Rehabilitation Institute cial test probes have been designed the Commonwealth of Massachu- at Tufts, as well as a number of af- for the client's use. This is an ex- setts in 1977 . It is believed that this filiated facilities . Staff members see ample of the application of rehabil- was the first time that Rehabilita- clients at the Crotched Mountain itation engineering in cooperation tion Engineering was officially rec- Center in Greenfield, New Hamp- with private industry and the state ognized by a state agency as a clin- shire, The Meeting Street School in agency . ical service. Shortly after that, the Providence, Rhode Island, and the State of Rhode Island approved a Massachusetts Hospital School in similar rate . In 1979 the Medicaid Canton, Massachusetts . Referrals program in Massachusetts ep- have been made from a number of provmdtheCentoreovendorofcus- agencies including the Vocational tomized inaortn, customized inter- Rehabilitation Programs in the six faces, and other nonstandard New England States, insurance equipment. companies, the Muscular Dystrophy The services offered include a Association, United Cerebral Palsy, gunerol equipment evaluadon, de- and the Spinal Cord Injury Founda- sign and construction of special de- tion. vices, modification of commercial With the exception of the Work- devices, and assistance in selecting station Evaluation and Design Grant, a commercial device. the service effort has succeeded in In 1978 the Center was awarded becoming self-sufficient . Fees an Innovation and Expansion Grant charged are similar to those of other to develop its skills in workstation clinical services. evaluation and design . This has TRAINING AND EDUCATION An important of any research and service program is the extension of its knowledge and ideas to others . The area of training is growing and will continue to be an exciting aspect of our Center's activities . Outlined below are a series of training activities in which we are involved.

Graduate Course in Rehabilitation Creative Engineering for Occupa- Engineering tional Therapy Students James O'Leary, Principal Instructor Richard Foulds, Principal Instructor This is part of the graduate curric- This course is part of the curricu- ulum of the Department of Engi- lum of the Tufts-Boston School of neering Design at Tufts University. Occupational Therapy . It explores The course includes an overview of concepts of creative technological the research being conducted na- problem-solving as well as expos- tionwide. Projects are drawn from ing students to the design andfab- the Center's activities in Client rication process . Projects drawn Service. from the o!inioal setting are required .

151 Bulletin of Prosthetics Research, ~~~~4 (Vol . 17 No . 2) Fall 1980

Rehabilitation Engineering Center New York University Medical Center Institute of Rehabilitation Medicine 400 East 34th Stree , New York, N .Y. 10016

Joseph Goodgold, M .D ., Director

Center staff : Mario Clagnaz, B.E.E., ipate in the study and had executed the 8. Effect of release of body lift sup- Biomedical Engineer ; Joelle Couni- necessary consent form. port strap after long duration otakis, M .Ed ., M.A., Research Psy- Patients were evaluated on the standing (> 10 minutes); chologist ; Ruth Dickey, B .S ., O .TR ., LaBerne Table in three separate trials. 9. Pressure of structural parts on pa- Occupational Therapist ; Francesca Initially the patient was set-up on the tient's body; Hoversten, Technical Secretary ; Hope device and the controls were handled 10. Tolerance to upright position; Juckel-Regan, B.S., R.N., Rehabilita- by the investigator. In the second trial 11. Assistance required to return to tion Nurse ; Robert Kolwicz, Mechan- the patient was instructed in self-op- sitting position; ical Engineer ; Henry Louie, A .A.S., Re- eration and assisted at times . The third 12. Assistance required for separation search Electronics Technician ; Mario trial was used to establish whether in- of wheelchair from frame Montreaux, B .S., Research Technician; dependent operation by the patient 13. Patient reaction to device; Reuven Ofir, M .A., R.P.T, Physical Ther- was possible . Fifteen parameters were 14. Skin reaction to support strap apist ; Kristlan Ragnarsson, M .D., evaluated: pressures; and Physiatrist ; Theobald Reich, M .D., Phy- 1 . Assistance required for placement 15. Comments. sician; G. Heiner Sell, M .D., Physiatrist; of body lift strap; Smvmrul problems that require struc- Carol Stratford, B.S., O.TR. Occupa- 2. Assistance required for placement tural modification of the table have tional Therapist ; Barbara Sweet, B .S., of wheelchair; been identified . The thoracic support O.TR., Occupational Therapist ; Myron 3. Assistance required for operation is not adequate to support trunk and Youdin, M .E.E., Rehabilitation Engi- of control box; hip extension in most patients (Fig . 1). neer; and Muriel Zimmerman, M .A., 4. Assistance required for controlling The anterior chest pad is not adjustable O.T:R., Occupational Therapist. body movement during ascent; enough to accommodate all patients 5. Assistance required for placement (Fig. 2), and the anchoring device of of thoracic support; the chest pad often protrudes into a Clinical and Engineering Evaluation of 6. Balance while in upright position; patient's abdomen (Fig . 3). Stationary Stand-Up Frames and 7. Stability while in upright position Preliminary observations indicate Stand-Up Wheelchairs for the Dis- for activities ; that paraplegic patients can operate all abled This TABLE 1. several types of stand-up devices for Physical Characteristics of Patients Evaluated in the LaBerne Gear Lift Stand-In Table. patients with spinal cord injury and Level other disabilities . To date, patients have Sensory Name Sex Age Height Weight of level evaluated the LaBerne Gearlift Stand- injury In Table (stationary frame) and the DT M 31 8'u^ 195 lb C3,4,5 intact Levo Stand-Up Wheelchair. Prior to clinical evaluation of pa- (incomplete) (incomplete) EC F 16 5'3" 110 lb C5 Cs tients, three ablebodied vounteers of varying heights and weights were set- BH M 20 6'2" 180!b C6 C6 RC M 32 5'8" 230 lb Cs C5 up in the devices to familiarize the in- KR F 21 5'5" 120 lb T5–6 T5–8 vestigators with the use of the device. ET F 20 5'6" 150 lb Co C7 Clinical evaluation was carried out TK M 53 6'0" 185 lb T7 T3–5 utilizing patients (Table 1) with para- plegia and quadriplegia from the adult in-patient services of the Institute of Rehabilitation Medicine who met the following requirements : TABLE 2. 1 . The patient was medically stable Physical Characteristics of Patients Evaluated in the Levo Stand-Up Wheelchair. and had the approval of the attending Level physician to participate in the study; Name Sex Age Height Weight of Sensory 2. The patient could tolerate the up- injury level right position on a tilt table for a period ET F 20 s'er 150 lb C6 C7 of at least 1 hour ; and Tx M 53 8'n^ 185 lb T7 T3–5 3. The patient was willing to partic- KR F 21 s's^ 120 lb T T 6 152 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

FIGURE 2. Anterior chest pad not adjustable enough for all patients.

FIGURE 1. Inadequate support for trunk and hip extension .

FIGURE 4. Uneven strap pull created balance problems for all patients.

FIGURE 3. Chest pad anchoring device is seen protruding into patient's abdomen in this view from below table level . 153

Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

FIGURE 7. FIGURE 8. Chair frame pressure is illustrated in this close-up photograph . Lack of upper-body balance limits hand functions .

154 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

eupocte. of the device independently, bonofromthe manual are shown in A series of internal meetings with while quadriplegic patients require the Figure 9. patients of the Institute are being ar- assistance of 1–2 people for placement The text and essential illustrations ranged to discuss their concerns and of the body lift support straps and 'I of the manual are being circulated to to clear up their anticipated "electrical" person for placement of the wheelchair all involved departments of the Insti- problems, prior to their return to home and operation of the mechanism . Un- tute, the !R yW Bioengineering Group°, and job. even pull of the straps created balance and to experts at other REC Centers for problems in all patients ; equalization review. After review and editing to in- of pull was much easier in the para- clude suggested additions and modi- plegic population (Fig . 4). fications, the manual will be submitted Upon completion of the nnodifioa- for publication and distribution . We are tionn ' the LaBerne table will be eval- designing a demonstration project to uated in the homemaking and prevo- be located in the Laboratory for Inde- cational areas. pendent Living in which many of the devices described in the manual will Patients (Table II) have been evalu- be available for the disabled con- ated on the Levo Stand-Up Wheelchair sumers, their families and members of (Fig . 5). Twelve parameters were eval- the staff to see and work with ; for ex- uated: ample : receptacles, switches, circuit 1. Assistance required to transfer into breakers, wire units, basic tools, sam- chair; ples of 2-conductor and 3-conductor a The IRM Bioengineering Group consists of 2. Assistance required for placement wire cord, examples of frayed and a core of experts from Bell Labs, AT&T, and of support straps; properly terminated extension cords, the N .Y. Telephone Company who meet 3. Assistance required for operation regularly with the IRM staff to provide con- fuses, fuse pullers, etc. A chapter is sultation and suggested solutions to prob- of chair; included on lead-acid batteries, gel lems pertaining to electrical and mechan- 4. Balance of patient in upright po- cells, and battery chargers . ical devices and associated research. sition; 5. Stability of chair; 6. Pressure of structural parts; --APPLIANCE WITH METAL CASE ELECTRICA ENERGY 15 CONVERTED TO HEAT AND LIGHT 7. Mobility of device; --INSULATED TERMINAL BOARD 8. Adjustability for patient; 9. Time tolerance; 10. Reach; 11. Return to seat; and 12. Transfer out of Levo chair. Pressure areas from the knee pads HEAVY COPPER WIRE FINE TUNGSTEN WIRE IS GOOD CONDUCTOR IS POOR CONDUCTOR and chair frame (Fig . 6 and 7) are sig- OF ELECTRICITY. OF ELECTRICITY. nificant problems limiting time expo- VERY SMALL FRACTION ALMOST ALL OF 110 V OF 110V REQUIRED TO REQUIRED TO FORCE sure in chair. Lack of upper body bal- FORCE CURRENT THRU . CURRENT THRU. SAME CURRENT FLOWS THRU BOTH ance in the standing position limits use AND DRILL OR OTHER APR IANCE POWERof the hands for function (Fig . 8). En- DISSIPATEDITH METAL CASE POWER DISSIPATED = = ^ AMBERES •v NEGLIGIBLE VOLTS ^AM=RES v=E& ENT== INSULATED TERMINAL BOARD gineering evaluation of the above POWER -Av WATTS POWER = AV WATTS problems has been initiated ; adapta- = NEGLIGIBLE = ALMOST ALL POWER -NO POWER tions to the chair are necessary to fa- cilitate further clinical trails. TOASTER OVEN POWER= 1500 WATTS 1500 I5A FUSE 110 WILL PERMIT OPERATION OF A "Know-How" Manual on Electricity THIS OR THIS-\._ B UT NOT BOTH - for the Severely Disabled and Their MULTANEOUSLY Families In the preparation of this manual fire departments, telephone companies, electrical component manufacturers COFFEE POT and distributors, and the National Fire POWER =475 WATTS 475 Protection Association have been con- HOW TO CALCULATE CURRENT CURRENT =—= 4 3A tacted for advice and for their dieirib- FROM WATTAGE RATING AND VOLTAGE : WATTS utab!oinfornnudon . Occupational tha p DAMP SPOT CURRENT = voLTs IN AMPERES apista,homeeoonomiotnandp!onnam ' and the Paralyzed Veterans of America FIGURE 9. have all contributed their expertise A few of the illustrations taken from IRM's "A 'Know-How' Manual on Electricity for the (see references) . Afnvv of the il!uotra' Severely Disabled and their Families ." 155 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

Bibliography Electronic Telephones and Controls: Most of the quadriplegic patients Patient Safety : Hewlett Packard Company GTE Speakerphone ; Panasonic Speak- seen at this Spinal Cord Injury Center 1971. erphone; Prentke-Romich ADT-5B, return to college after their rehabili- Stroke: John E . Sarno, M.D, Martha Taylor Rapidial; Royce Freedom Dialer ; Te- tation, or otherwise attempt independ- Sarno, New York, McGraw-Hill, 1979. leconcepts Memory Dialer. ent living . It is therefore necessary to Basic Medical Electronics : Rudolph C . Cam- provide braking systems which will ishior, M .D., Boston ; Little, Brown & Co., 1964. Mmb!byComtm.!ohmPuxeered yVheel- enable these users to control their Indoor Home Repairs Made Easy : Peter ohain» : MED 24 Volt Quad Systems wheelchairs as they travel up or down Jones, Butterick Publishing 1979. with Pneumatic, Short-throw and the ramps and other inclines which are Basic Electricity : Van Valkenburgh, Nooger encountered on public streets and/or & Neville, Inc ., Hayden Book Co ., Inc., Rocker Control Switches ; Romich, 1979. Beery & Bayer Du-It Systems; Thresh- private areas. Aids for the Severely Handicapped : Edited old Technology/IRM Prototype Voice Inquiries made of the major wheel- by Keith Copeland, Sector Publishing Control for aModified E8J3P chair manufacturers and distributors Limited, 1974. confirmed the fact that the required Know-How: Guy Alland, Miron Waskiw and Tony Hiss, Boston ; Little, Brown & Co ., Audio Recorder Controls : Clinical Con- braking systems would not be avail- 1975 venience Products Control for a Lanier able commercially (or on custom or- Home Clinic (Articles) : Bernard Gladstone, dictating machine ; Romich, Beery & der) from them in the forseeable fu- The New York Times Bayer Easicorder ; Sony Magic Wand; ture. In order to satisfy the need of IRM "Steps to Take When a Storm Threatens your Electric Service" ("If you Use Life- CummutvonTDSL-2 Recorder Control patients the research and development Sustaining Equipment") : William G. Lent, for a Sony Dictaphone. as described below has been accom- Coordinator Public Affairs, Consolidated plished. Edison Co ., New York. Electric Door Controls : Besam Com- At IRM it has been concluded that "Wheeling to Fire Safety" mercial Opener; Keane Monroe Light the optimum braking system is one "Home in a Wheelchair" "Wheelchair in the Kitchen" Duty Automatic Door Operator Series which operates in a manner analogous Eastern Paralyzed Veterans Assn . U.S.A., 100; Power Access Automatic Door to the braking system in an automo- New York. Opener Model 4300. bile, especially since almost all of our "Planned Escape from Fire" patients were drivers prior totheir dis- "This Fatal Electrical Fire was Preventable" Fire Dept . New York City Alphanumeric Format Communica- abling accidents and are thoroughly "The Home Pro Guide to Electrical Instal- tion Aids : Possum Controls Hi-Speed familiar with the operation of such a lation and Repair" : Minnesota Mining Typewriter W1ode! 3A ; Possum Con- system . Thus we would like the braking & Manufacturing Co ., 1975 trols Scanner Typewriter Model 1A/5A; system to perform as follows: National Electrical Code 1978 : National Fire Protection Association. Canon Communicator ; Elkomi; Phonic 1. Brakes can be applied manually, by Testing for Public Safety : Underwriters Lab- Mirror Handivoice K8odo! 110 ; Speak broath oontro! <^puff and oip"> or by oratories Inc . 1979. and Spell ; Talking Brooch. voice control; 2. Brakes are applied as required, by Electric Page Turners : Bard-Carba R-2; the driver, in the same manner as he Evaluation of Electronic Self-Help De- GEVVA ; MED-Brusse. would brake if he were driving an vices for Use by Severely Disabled automobile; Persons 3. Brakes should also function as park- Braking Systems for Powered Wheel- ing/transfer brakes provided they can Summarized interim findings were chairs for the Severely Disabled compiled within the last quarter on all be released without the need for a sep- devices currently under evaluation for Aapart ofourresearch into thmfunc- arate manual disconnect; inclusion within the Center Annual Re- tional padbnnanouofinotmmontudnn 4. Brakes operate independently of port. A complete listing follows . Find- for the severely disabled, we discov- the wheelchair drive motors; ings on a single device or complete ered that powered wheelchairs are not 5. Braking action should be propor- device category are available on writ- available with brakes that can be con- tional; and ten request. trolled by a quadriplegic or other se- 6. Brakes are not interconnected to the verely disabled person . The normally drive controller and are controlled from Envi ! Controls : BSR/Sears supplied wheel lock levers are a form a separate switch (or transducer). Remote Control System ; Bard-Carba of transfer brake which can only be Our system would differ from what Environmental Control System ; Com- engaged or disengaged by an attend- Stout (1) considers to be a "good brak- ant. "Emergency stop" switches, when inguyotem^Stout op*cifieothat^The provided, remove power from the drive switch which sets the brakes also in- Romich ECU-1 ; Prentke-Romich ECU- wheels and are of no value for stopping terrupts power to the motors" . Such 2 ; Prentke-Romich PA-1 ; Prentke- a wheelchair which is travelling up or a switching arrangement would not down an incline . An owner's wheel- enable a wheelchair to stop on upward Style Nurse Call/l Function Cable; chair manual supplied byon*manu- sloping terrain and then resume up- Threshold Technology/IRM Prototype facturer contains the safety precau- ward travel . For example : The brakes Voice Control for ECU-1 ; Warner Labs tion : "Do not attempt to go up or down must be applied to hold the chair on Whistle System 3 ; Western Technical a steep ramp or grade unless there is the slope . It would then not be possible Products' Genie . aomoonotoauoiatyou^ to apply power to the motors to enable

156 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

It has been our observation that the UPON STOPPING, CHAR WILL ROLL usual reason for loss of power is that BACmUARDS AND/ CHAIR ASCENDING batteries have not been adequately re- SWERVE TO LEFT SLOPE IN FORWARD DIRECTION charged. To warn the driver of im- pending failure there is now a battery voltage indicator light on the control begins to flash when the battery voltage SIDEWALK INCLINED drops below the preset level . This is SLIGHTLY TO RIGHT an indication that the batteries should FIGURE 10. be charged as soon as possible . Since Backward and swerving motion of a powered wheelchair when stopped on the wheelchair is so important to the a sideways tilted inclined terrain . disabled user, it is incumbent on him to maintain the batteries in a charged MASTER CYLINDER condition and in so doing minimize the number of incidents of power loss. In our previous report we described mechancial and hydraulic braking sys- mmGHr DRIVE WHEEL tems developed at REC/IRM . After evaluation we have decided to discard the mechanical system and to continue our development on the following improved version of the hydraulic system. This system utilizes caliper disc brakes which are actuated hydrauli- cally from a master cylinder. Two separate sets of brakes are required . A schematic drawing of the system is shown in Figure 11 . A small geared electric motor is used to generate the input force to the master cylinder : see Figure 12. Further clinical trials of this system are required to evaluate its range of usefulness, reliability, and acceptabil- ity by the disabled user. It is intended to continue development of this system and simplify the design so that the brakes can be reduced to a package easily adapted to any powered wheelchair for the severely disabled. 7 References FIGURE 11. 1. Wheelchair-ll Report of Workshop, Dec. Schematic of hydraulic brake system . 1979, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadel- phia, Pennsylvania 19141, pp . 62-63. 2. Private communication from New York the chair to continue its travel without plication of brakes occur upon inter- State Office of Vocational Rehabilitation. first releasing the brakes. Our experi- ruption of power to brakes" . This ence an E&J Model 3P chair on arrangement requires the addition of a 10-12-deg sloping surface which also still another system : ". . . a monual New Aids for Independent Living for slopes slightly sideways (see Figure disconnect to allow manual pushing the Severely Disabled 10) has been that when the brakes are of the chair" . There are reports (2) in released the chair will no!l backwards which disabled users of powered (Subtask 1 : Remote Door Controls for and will also spin or swerve to one wheelchairs (in which brakes set upon the Severely Disabled) side. This action can easily be avoided interruption of power to the brakes) One aspect of our investigations into when forward power is applied prior were seriously injured when the chair the functional performance of instru- to releasing the brakes—for this rea- lost povver, stalled in a dangerous lo- mentation for the severely disabled son we would not automatically set the cation, and could not be moved be- has been directed towards providing brakes when the motors are not en- cause passersby could not operate the independent access to apartment energized . Stout also specifies that ^Ap- manual disconnect. trances . There has been an increase in 157 Bulletin of Prosthetics Research, BPR 10~(V~17 No . 2) Fall 1980

above have been interconnected to provide operation as follows: The user approaches the door (Fig . 14) and stops. A "puff" unlocks the door (a buzzer sounds when the lock release is energized) . Simultaneously, the door opener is energized and the door opens and remains open for an adjustable preset interval. The user then proceeds through the door and enters the room (Fig. 15). At the end of a preset interval the door closes and locks. The same procedure is followed when leaving the room. The system has certain advantages: (i) The door can always be unlocked with a key even in the event of a power failure, (ii) The door can be opened and closed manually at any time independent of the opener, and (iii) The FIGURE 12. 1024 possible combinations provide Small geared electric motor drives cam to displace piston in hydraulic master cylinder. The the user with a private and personal electric motor drive provides : (i) proportional braking action, (ii) a transfer and emergency brake requiring no drain from the battery, and (iii) a convenient means of releasing the "key" for his door. The combination brakes to allow manual pushing of the chair. can easily be changed periodically for additional security. A possible disadvantage is that the accessibility to public and commercial lected because they are commercially building entrances for the handi- available. lock does not provide a "dead bolt" capped (airports, theatres, recreational Remote actuation of door openers which may be desirable in certain ur- facilities, churches, etc.), but there is has been accomplished in the past by banaroua. still need for increased accessibility to means of radio control systems entrances of private homes, apart- wherein transmitters and receivers are ments and offices. matched to one another by frequency The objective of this task is to de- selection. Inherent disadvantages of velop systems which will enable a se- this type of control are the limited verely disabled person to lock and un- number of available carrier frequen- lock the door to his apartment without cies and the possibility of a match be- the use of a conventional type of key tween transmitter and operator be- and without the need to turn a door longing to different persons. knob. The special transmitter which we An environmental control system employ produces a repeating series of can be utilized in conjunction with a time modulated pulses, the individual magnetically operated door strike to timing characters of which are deter- enable a disabled person (once inside mined by the conditions of a series of his room) to unlock and open the door two-position switches . The receiver, to a visitor, or to close and lock the which is mounted in the door opener, door after the visitor has gone . He can- is responsive only to the same series not use the system to gain entrance of predetermined pulse characters. The from outside the room . He usually transmitter operates at 300 MHz . and does not have sufficient manual dex- transmits 10-bit digital words utilizing terity to insert a key into a lock or to a binary code over a 60-foot radius turn a door knob. What he requires for under worst conditions. Utilization of this task is some means of unlocking a dual-in-line 10-position switch makes the door and not having to turn the it possible to provide 1024 <210> pos- doorknob . One of our solutions to this sible lock combinations : see Figure 13. problem utilizes a radio frequency (A three-digit commercial combination transmitter (1) which we have adapted lock, by comparison, has only 1000 for pneumatic actuation and mounted <103 > possible combinations .) The elec- transmitter is operated from a breath FIGURE 13. tromagnetically actuated door lock (2); tube located adjacent to the one used Dual-in-line 10 position switch utilized in the and a motor driven door opener (3). to control the wheelchair. RF Transmitter makes possible 1024 (2 1 0) se- The three components described different lock combinations . 158 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

FIGURE 14. FIGURE 15. The door lock includes an electromagnetically controlled strike The door-opener has a motor-driven arm, at the end of which is plate . The strike plate is normally in the locked position . When mounted a small roller. When actuated, the arm swings out of its the door control is actuated the strike plate is released enabling enclosure and pushes the door open, with the roller accommodating the door to be pushed open . the relative movement of the door, The door is maintained in the open position until a second signal is transmitted . There is no permanent connection between the door and the door opener : the opener is Subtayh 2 : Control of Environmental mounted on the door frame . A feature of this type of opener is the impossibility of the door being jammed in the closed position by the Control System from Remote opener. Locations Considerable effort has been ox- phyoioal movement, an array ofelec- of this task is to investigate means of pmndod, especially since the early trical devices or appliances. We have controlling the appliances previously 1970'o' to develop new electronic as- previously reported the results of a described from the powered vvhee!- sistive devices for the severely dis- c!inioal evaluation of available envi- chair' i.e., pruviding "frem nanging^ abled . These devices have enabled the ronmental oontml systems (4) ; the re- control of the environmental control severely physically disabled individual sults of a study to optimize the design system. Such a system would widen to function with greater independence. and utilization of environmental con- the user's office and home work area, Two of the most useful of these devices trols systems (5) ; and the impact of and provide him with greater freedom are the pneumatic ("puff" and "sip") electronic assistive devices on the of movement and increased independ- oontnul which when assembled onto quality of life of high !ovel quadri- ence. a powered wheelchair enables the dis- plegics (6). The scanner display of the environ- abled user to control wheelchair move- The environmental control system mental control system is shown in Fig- ment by blowing into (or sucking on) (ECS) previously described must be ure 16 . By electronically interfacing the a mouth tube and the environmental operated from the fixed locations where ECS with the same (or similar) RF control system which is an electronic the pneumatic transducers are located. transmitter descibed in "Subtask 1", scanner-switch that enables a disabled This seriously limits the freedom of it is now possible to control all of the user to control, by breath or limited movement of the user. The objective pariphmral devices manually or by

159 Bulletin of Prosthetics Research, BPR 10~(V~17 No . 2) Fall 1980

"puff" and "sip" control while moving 6. Couniotakis J, Gordon W, Sell GH, Strat- search, 0HD/Department of Health and about in the powered wheelchair. The ford C"TmImpact of Electronic Assis- Human Services, Grant No . 16-P-56801- tive Devices on the Quality of Life of High operating radius is approximately 50 Level Quadriplegics", accepted for pub- 17. feet. The remote door control system and remote ECS have been installed in the INFORMATION DISSEMINATION IRM Independent Living Laboratory Acknowledgement where they are undergoing evaluation This work has been supported by Research Utilization Activities by patients and staff . The PovverA6' grants from the Charles A. Dana Foun- 1 . More than 600 people have visited cess b Automatic Door Opener (Model dation, the Nate B . and Frances Spin- the!RK8/NYUIndependent Living Lab- 4300) shown in Figure 14 does not re- gold Foundation, the Hearst Founda' oratory during the last six months. quire the door opener arm to be phys- tion. Mrs. Henry L. Moses, United These include: ically attached to the doors : the opener Cerebral Palsy Research and Educa- Architects is mounted onto the door frame and tional Foundation, Inc . and the Na- Behavioral Scientists the door is "pushed" open by an arm tional Institute of Handicapped Re- Community Recreation Specialists which swings out of the opener enclosure. The mechanism retracts to permit the door to close . Since there is no physical attachment of the opener to the door, a standard door check is also sLE, * vw required . The Power Access unit has the advantage that the door can under no circumstance be jammed in the closed position. The Keane Monroe° Automatic Opener is a smaller and less obtrusive device . Its arm must be physically attached to the door. In order to me- chanically override the opener, it is necessary to apply enough force to the door to cause a clutch to slip . The features of these and other door openers ENVIRONMENTAL CONTROL UNIT ENVIRONMENTAL IIT are now being studied in greater detail. TELEPHONE

References 1. Multi-Code Transmitter : Model No . 1087 and Receiver: Model No . 1090, manufactured by Multi-Elmac Co ., 22700 Hes- lip Drive, Novi, Mich . 48050. 2. Model 019 Remote Door Opener Control Kit and the DL-1 and DL-2 Door Indicator Lights, manufactured by Trine Manufac- turing Corp ., Bronx, N .Y. 10461. 3. Model 4300 Door Opener, Manufactured ENVIRONMENTAL CONTROL UNIT by Power Access Corp ., Eatontown, N .J. RONMENTAL CONTROL UNIT

07724. TELEPHONE 4. "Environmental Control Systems and Vocational Aids for Persons with High Level Ouad,ip!ooia .^ Rehabi!itatiun Monograph No . 55, Institute of Rehabil- itation Medicine, NYU Medical Center, 1979. 5. Youdin xx ' SvUGH ' ReicmTQaonozW4 ' Dickey R, Louis H, Kolwicz R : "A New Concept in the Design and Utilization of Environmental Control Instruments for the Severely Disabled" . IEEE/Conference on Engineering in Medicine and Biology, Denver, Col ., 1979. FIGURE 16. bPower Access Corp., Eatontown, New Operation of the electric scanner and switch . Selection of a function is accomplished by Jersey 07724 "puffing" into one of the breath tubes. Each "puff" advances the switch through one step "Keane Monroe Corp ., Monroe, North as shown by the illuminating light emitting diodes (LEDs) . A function is turned on by a Carolina 28110 "sip" and turned off by a second "sip' S

160 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

Environmental Psychologists 4. Films: 7. "The Bilateral Limb Amputee", Educators and Students ZDF German Television, North Chapter 14. I n yWoCoU h N .C . Ill Home Economists American Bureau ; Documentary for AAOS (Ed.) : Atlas on Limb Prosthetics: Hospital Administrators the International Year of the Handi- Surgical and Prosthetic Principles. Hospital Admissions Officers capped. Lehneis, H .R., Dickey, R . St. Louis, C .V. Insurance Counselors Documentary—Voice Control De- Mosby Co ., 1980. Nurses vices for the Severely Disabled ; Du- Occupational Therapists ponaProduotiona. 6. Cooperative Relationship Patients' Families Film Segments for United Cerebral The Research Division of the Inter- Physical Therapists Palsy Telethon. national Business Machines Corp. will Physicians participate with the Rehabilitation En- Sheltered Workshop Directors 5. Publications: gineering Center of IRM in a joint study Social Workers 1. "An Update of IRM/NYU Activities to investigate the applications of Speech Therapists in Instrumentation for the Severely speech recognition systems to the vo- State Housing Authorities Dioab!ud^ : Youdin, M ., Dickey, R ., Sell, cational rehabilitation of quadriplegic Therapeutic Recreation Specialists G8 . Stratford, C. Model Systems patients . In particular, the study will Vocational Rehabilitation Spinal Cord Injury Digest. explore the feasibility of the use of Counselors 2. "Voice Control : Clinical Evalua- speech actuated computing facilities Countries represented by visitors tion by Persons with Severe Physical by quadriplegics for generating com- to the IRM/NYU Independent Living Disabilities, With and Without Speech puter programs as a possible means Laboratory during the last six !mpaimnont' : Stratford, C ., Dickey, R ., of gainful employment. months: Zimmerman, K8 .' Ynudin' N1,Sell, G8 Interagency Conference on Rehabili- Argentina India tation Engineering, June 16-20, 1980, Australia holy Toronto, Canada. Brazil Japan 3. "Application of Voice and/or Canada Luxemburg Breath Controls for Powered Wheel- Colombia Mexico chairs and Environmental Equipment Denmark Russia fortheCermbra!Pa!oied^ : Zimmermen Sri Lanka ' Egypt K8 .E.Ybudin K8,Sarno, M,Sell, G8. Finland Surinam ' Feder, C . Report on research to United Germany Switzerland Cerebral Palsy Research and Education Greece Vietnam Foundation. in addition zhere were 50 from Eu- 4. "Braking Systems for Powered rope and the Middle East, affiliated Wheelchairs for the Severely Dio- with the United Nations and touring ab!ed^ : Youdin, M ., Reich, I, Sell, G .H ., under the sponsorship of intmr- Louie, H ., Clagnaz, M ., Kolwicz, R . Ac- national hospitality committee of the cepted for presentation at the Inter- National Council of Women of the agency Conference on Rehabilitation United States, and others representing Engineering, June 16–20 ' 1980, Tb- most of the 50 states and District of nunto .Cenado. Columbia. 5. "A Voice Controlled Powered Wheelchair and Environmental Con' 2. Fifty Lectures and Demonstrations tvo!ByotemfortheSovam!yDiaub!od^: of our instrumentation were presented Youdin, M., Sell, G8 ' Reich, T, Clag- to visiting Scientists, both national and naz, M ., Louie, H., Kolwicz, R . V Inter- international. national Conference on Medical Phys- ics and Xll International Conference on 3. Clinical lectures given at IRM by R. Medical and Biological Engineering, Dickey: Jerusalem, Israel, August 1S-24 ' 1978. 1. OVR counselors—3 Lectures; 6. "Ongoing Research to Provide 2. Placement Seminar—college Greater Freedom of Movement and In- placement counselors; creased Independence for the Severely 3. OT–PT–Nursing Lecture, Inter- Diaab!ed^ : Youdin, M., Clagnaz, M., hospital Seminar; Dickey, R ., Kolwicz, R ., Louie, H ., Reich, 4. Insurance Seminars—3 Lec- T. Sell, G .H. Submitted for presenta- tures; tion at the Annual Conference of the 5. New York University Occupa- IEEE Engineering in Medicine and Bi- tional Therapy Students o!ogySooioty, September 28–29, 1980, 3 Lectures; and Washington, D .C. 6. Columbia University OT Stu- dents 2 Lectures. 161

Rehabilitation Engineering Center time can be used yielding high signal- Harvard University/Massachusetts Institute of to-noise ratios whereas during rapid movement, short processing times can Technology be used yielding high bandwidth. 300 Longwood Ave., Boston, Mass . 02115 A high-fidelity forward (or com- William Berenberg, M.D., Director ; Robert W. Mann, Sc.D., Melvin J. mand) pathway should provide the Glimcher, M .D., and John E. Hall, M. D., Assoc. Directors disabled user with the same adaptive capabilities the able-bodied user en- The various projects under way at operative management regimen which joys. Work is currently in progress to this REC were briefly described in the will increase the likelihood of a suc- implement a previously developed BPR, Fall 1979 issue . In addition, a de- cessful outcome. control system which will give, to a tailed article, "A TSPS Telephone Con- high-performance electromechanical sole for Blind Operators : Technology Neurophysiological Feedback pr;!osthesis, tunable compliances sim- Transfer in Action" by George F. Dal- from Extremities ilar to those of the natural limb. rymple and Derek Rowell, was in- Project responsibility, Neville Hogan, cluded in the Spring 1980 issue. Ph.D.; Research assistant, Loretta 11re of a New Biofeedback and Gait- A progress report on six current Deming Analysis System in Conjunction with projects follows, with reports on the the Microcomputer-Controlled balance of REC projects scheduled to A major obstacle impeding wide- Above-Knee Prosthesis appear in BPR 10-35, Spring 1981. spread user-acceptance of myoelec- Project responsibility, Woodie Flow- trically controlled devices is the level ers, Ph. D.; Research Assistant, Mi- Monitoring, Modifying, and of concentration required for their op- chael Shepley Testing Anterior Spinal eration. Typical myoelectric controllers Instrumentation are inaccurate and require the operator A microcomputer-controlled above- to compensate for their inadequacies Project responsibility : Derek knee prosthesis developed at this REC Rowell, Ph .D., and John by using external feedback, typically was used to evaluate an immediate visual or auditory Hall, M .D. Research staff: . This increases the postoperative training program in mental workload placed on the oper- Mark Orton, Robert Reilly which the versatility of the new pros- ator to the extent that it can offset the thesis provided a more gradual tran- A passively powered telemetry unit, improved functional capabilities pro- sition from a locked pylon to a pros- which monitors tension in the cable vided by the assistive device. thesis which has characteristics very incorporated in the Dwyer apparatus, The object of this project is to de- similar to the intended permanent was designed and successfully tested termine to what extent a high-fidelity prosthesis . Interaction with the first in vivo in dogs for a period of one year. forward path will reduce dependence four patients in the new program, and Data acquired indicated that smaller on external sensory feedback . The ul- with the clinical staff at Massachusetts power drain and improved accuracy timate goal is to exploit the inherent General Hospital, pointed out that sev- were obtained through the redesign of proprioception of muscles, subsituting eral other gait training problems might the implanted electronics and imple- it for external visual or auditory feed- be addressed by use of additional in- mented on a semi-custom integrated back. strumentation for the prosthesis and circuit. The modified unit was recently The focus of efforts during the past microcomputer system . During the past used during a Dwyer operating-room year has been on digital implementa- year, weightbearing and knee torque procedure in a human patient to mea- tion of a recently improved myoelectric transducers were added, and a bio- sure cable tensions. signal processor (Fig . 1 and 2). A major feedback and signal-processing inter- Development efforts are presently advantage of digital implementation face was built . These additions made focused in two areas. The micropro- is that the required calibration can be recording and display of several gait cessor-based receiving instrument is performed automatically. Automatic parameters straightforward . The fol- being redesigned to reflect changes in calibration will permit us to maintain lowing are now possible outputs: the implant electronics and to simplify processor fidelity under conditions of An analog weightbearing signal; operation of the instrument. The load muscle fatigue. The typical myoelectric An audible tone indicating that cell and transducer package are also signal processor cannot operate under weightbearing is above or below an being redesigned so they are more conditions of fatigue because the char- adjustable level; physically compatible with the ana- acteristics of the signal change drast- A stance cue; tomical structures in humans. ically. Further investigation is being An analog knee torque signal; The goal of the project is to make conducted into an adaptive signal pro- An audible tone indicating that knee available to the orthopedist accurate cessor whose processing time changes' torque is above or below an adjustable measurements of the cable tension for to match the changing signal charac- level; an indefinite period of time; this should teristics. If the muscles are attempting Knee angle; allow the design of an individual post- to maintain posture, a long processing Knee rotational velocity ;

162 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

w 0

4 ACTUAL PROCESSOR FORCE OUTPUT

0.5 1 .0 1 .5 2 .0 2.5 0.5 1 .0 1 .5 2.0 2 .5 TIME IN SECONDS TIME IN SECONDS FIGURE 1. FIGURE 2. Typical myoelectric signal-processor performance . Improved myoelectric signal-processor performance.

An analog knee power dissipation propriate energy-absorbing loads invasive, automated, on-line, real-time signal ; and across afflicted joints. calculation of the median frequency of An analog signol representing en- In one-degree-of-freedom (wrist ex- the EMG aiAnul spectrum. Ourtheo- ergydiaoipudon per cycle or per unit tension/flexion) tests to date, tremor retical calculations have shown that time. measured during visually mediated the median frequency is the preferred These outputs can be used in con- pursuit tracking tasks was reduced by parameter that relates the character- nection with the versatile prosthesis statistically (and often clinically) sig- istics of the EMG signal to metabolic controller to provide gait training pro- nificant amounts by the application of changes within the muscles that are grams which more precisely address a rotational viscous load . Qualitatively associated with fatigue . Figure 6 pre- the particular patient's problems. Two similar results have now been achieved sents the prototype version (on the patients (one young and one geriatric) in six subjects disabled by a variety of right) and a substantially smaller, eas- have had postoperative training using congmnita!, ucquired, and degenera- ier-to-operate version for clinical use the new features . In both cases, bio- tive conditions . (Results for three sub- (on the left). The clinical version was feedback based on weightbearing and jects are graphically presented in Fig- designed with the help of substantial knee torque was a very effective train- ure 3.) The experimental protocol input from clinicians . It has several ing aid ; both the therapist and the pa- includes recording of joint angle and particularly useful features : it is con- tient found that knowing when a preset angular acceleration signals, applied veniently portable (battery operated) threshold was reached could be very damping torque, and two channels of and it provides a continuous numerical beneficial. The knee torque biofeed- extensor and flexor EMG . These data and discrete display of the median fre- back was particularly uoeful for im- will be used to establish mechanisms quency. Various fail-safe features in- proving stability and confidence dur- forth* observed effect on tremor and tended to eliminate improper usage ing stance. for the tremor itself. are provided. Results to date indicate that elec- Direct clinical application of the The prototype version was used in tronically controlled prostheses above results has begun in the form a series of experiments on normal sub- equipped with transducers which of a prototype damped joystick as an jects to investigate the appropriate- monitor gait parameters may allow a adaptive interface forcontrol ofwheel- ness of the median frequency as a uubstantial improvement in rehabili- chairs and of communication and en- muscle metabolic-fatigue index . The tation. vironmental control systems . Data pre- results were consistent with the known sented at the 2nd Interagency behaviour of the conduction velocity Suppression of Abnormal Involuntary Conference on Rehabilitation Engi- of the muscle fibers which is related Movements by Application of Me- neering (Fig . 4 and 5) show two-di- to the pH of muscle tissue . Further- chanioa!Lmmds and Biofeedback mensional tremor-reduction during more, it was found that the value of Project responsibility, Michael J . Rn- figure-tracing that is consistent with the median frequency is highly re- the one-dimensional results . Work is peatable (consistent) during similar oen' Ph.D.; Research assistant, Dov Adelstein underway to build a unit of practical contractions performed on different size and evaluate it clinically. days (Fi g . 7). A series of experiments The goal of this project is the de- are in progress to document the be- velopment of techniques for returning Automated Muscle-Fatigue Indicator havior of the median frequency as a function to neurologically impaired in- Project responsibility, Carlo J. De Luca, function of muscle, force, and type of dividuals who are disabled by tremor contraction. Ph .D.; Research staff, Alan Oslan, M. Various uses of the clinical version in spite of usable levels of residual Sc. strength and voluntary control . The of the device are currently being stud- hypothesis being tested is that selec- The Muscle Fatigue Monitor (MFM), ied by physical therapists . The studies tive attenuation of ubnormul tremor which has been designed and con- include a comparison of the behavior may be achieved by application of ap- structed of the median frequency of contralat- 163 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

Evaluation and Application of Myoelectric Biofeedback Project responsibility, Carlo J. De Luca, Ph. D. The REC has developed an econom- ical, wearable, myoelectric biofeedback unit optimized for simplicity of use by practitioners and patients (Fig. 8). Output is by both sound and light, simultaneously, if desired . The unit contains a paste-less electrode, which requires no preparation time for se- curing it to the skin ; this represents a aubutundol improvement over other available systems and renders the device unoful in busy o!inioul environments and at home . The unit's small size (11 .4 x 5 .7 x 2 .9 cm) and light weight (180 gm) make it convenient for ambulatory usage . We are currently in the process of searching for a company to manufacture and distribute the device. Ten units have been built and are being evaluated in the physical therapy departments of six major hospitals in the Boston area . Over 700 patient applications have been documented (Ta- bles 1 and 2) and it is estimated that the units have been used on well over 2000 patients thus far. The tables show that the clinicians used the device on a large variety of muscles of the upper TREMOR AND TRACK- and lower extremities and in all four ING VS DAMPING FOR application categories (but predomi- nantly in therapeutic exomine), dem- onstrating its versatility. Another clinical evaluation, to establish the types of neuromuscular dysfunctions which benefit from biofeedback therapy, is in progress.

FIGURE 3. Tremor and tracking versus damping for three abnormals.

eral muscles as a basis for referencing muscles during dynamic exercises . In the performance of a dysfunctioned addition, a study is in progress to in- muscle undergoing rehabilitation, and vestigate the use of the MFM for ob- a comparison of contractile fatigue jeotivoaoxesumont of progressive neu- (measured by a Cybex machine) and romuscular deterioration of patients metabolic fatigue in the quadriceps afflicted with Muscular Dystrophy.

164 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

-/ /

FIGURE 4 . FIGURE 5. Square-tracing performance of C .S. with no fluid in dampers . Square-tracing performance with dampers operational . (Darker (Darker rough square is target pattern .) rough square is target pattern .)

FIGURE 6 . The prototype version of the Muscle Fatigue Monitor (on the right) and the clinical version (on the !eft) .

165 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

100

M 75 E 0 se

A 25 25 N — : IPA— CIF 30 60 90 120

Y 25

—r— e * *1 1 0 30 60 90 120 0 30 60 90 120 n 100 IOC

75 75

50 SO

25 25 0 30 60 90 120 0 30 60 90 120 'TIDE in seconc{a

FIGURE 7. The median frequency during a sustained contraction . Each of the six graphs contains two curves obtained from the deltoid muscle of the same subject during an isometric constant- force contraction at 50% of the maximal force level on two separate occasions.

FIGURE 8. The myoelectric biofeedback device, the paste-less electrode and accompanying strap for attaching it to limbs.

166 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS TABLE TABLE 1 APPLICATIONS IN LOWER EXTREMITY II APPLICATION ON UPPER EXTREMITY 0 0 ~~ ~ m E °~ E to '~~~ to Mt— w to Q L. . ~ Muscle or ~u. 01 L. PO Muscle or co — 0 (0 ~~ w 4J w~ 0 Muscle ~ 1-- Muscle Group

Quadriceps 29 142 82 34 287 Intrinsics 8 7 7 22 Ant . T y b° 16 64 25 14 109 Ext . Carpi Radialis 8 7 6 21 Hamstrings 11 29 22 10 72 Biceps 17 3 1 21 Glut . Med . 0 32 22 14 58 Middle Deltoid ~8 0 0 18 Glut ° Max " 3 14 8 4 29 Triceps 10 3 1 14 Gastroc-Soleus 0 9 12 0 21 Ext . Digit . 13 0 1 14 Hip Flexors 0 5 1 0 6 Finger Flexors 3 0 0 3 Extensor 1 2 2 0 5 Pronator Teres 1 1 1 3 Peroneals 0 2 0 0 2 Post . Deltoid 2 0 0 2 Adductors 0l 0 0 1 Scapular Muse! . 2 0 0 2

Total 50 300 174 66 590 Total 82 21 17 120

Rehabilitation Engineering Center, Room 14441 Northwestern University 345 E. Superior Street Chicago, Illinois 60611

Clinton K. Compere, M .D., Project Director

Development and Evaluation of Total should also reduce system stresses, The value of these practices is being Knee Components and Surgical Pro- but whether or not this will occur de- evaluated by detailed followings of our cedures pends on how the cruciate ligaments clinical series . Of special interest in the Based on previous work in stress function on the living knee joint. This follow up is the possible increased analysis and ligament mechanics, a function is unknown at present. joint laxity without the anterior cru- totol knee system was designed in oo!- In addition to component design, ciate. Such laxity would allow joint !oboradonvvith Howmedica, Inc . The alterations in surgical procedures for loads detrimental to the implant. Fol- system, called the Kinematic® System installing the implants are being insti- lowing the clinical results will help to by Howmedica, consists of several tuted . Based on our studies of ligament determine the value of retaining the fomoral and tibial components, de- kinematics, special sequencing of bone anterior cruciate. signed for various ligamentous con- cuts has been devised to ensure proper As we gain confidence in our pro- ditions of the joint . The special features functioning of the cruciate ligaments cedures, we will incorporate them into of this system are one-piece metal after the implant is in place . Improved our education program for surgical trays with polyethylene inserts for d- methods for preparing the bony sur- residents and staff . By this combined bial oomponento, and two tibial com- faces, and use of low viscosity (sticky) effort in denign, procedure devu!op- ponents compatible with either intact instead of high-viscosity (dough-like) nnontund evaluation, and education, or absent anterior cruciate ligaments, cement in selected circumstances, are we hope to address the main causes respectively. The type for intact ante- also being done. The goal is to acquire of knee-replacement failure and make rior cruciate was designed by NUREP. a complete set of components, surgical it a more reliable procedure. The configurations and materials were techniques, and ourgioal instrumen- chosen to reduce stress levels between tation which embodies the results both bone and cement, and within cement of our research and that of others for and bone, with a goal of reducing the the optimal total knee system within incidence of loosening of iibiul com- the limits of the current state of the art. ponents, which has been the major As this system is completed, we are problem with total knees in the past. adopting it in our clinical practice of Retention of an intact anterior cruciate joint replacement . 167 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

Rehabilitation Engineering Center tained by measuring muscle length change while lengthening by pull- Case Western Reserve University ing on the severed tendon and dur- Cleveland Metropolitan General—Highland ing shortening while stimulating the View Hospital, Department of Orthopaedics muscle . Comparing this measure- 3395 Scranton Road, Cleveland, Ohio 44109 ment with the required excursion enables us to determine whether a muscle is sufficient to provide the Charles H . Herndon, M .D., Project Director desired function . Excursion measurements are shown in Figures la and b compared to published data The activities of the Rehabilitation lation is closely allied with that on- (1, 2) . These data represent the only Engineering Center at Case Western going in the Applied Neural Control known measurements of the excur- Reserve University are directed to- Laboratory and the Engineering De- sion (or physiological range) of in- ward restoration of function in pa- sign Center at C .W .R .U . In these tact human muscles recorded in tients with mobility disorders. Stud- studies, the feasibility of new upper vivo.' These data show that excur- ies are directed toward development extremity systems is being investi- sion in passive lengthening of the of a comprehensive program for gated, and a radio-frequency pow- muscle due to stretching generally restoration of upper extremity func- ered and controlled implantable was less than half of the unloaded tion involving both tendon transfer stimulator is being developed, re- active shortening due to stimula- and functional electrical stimula- spectively. tion . Thus, passive stetching pro- tion . Mobility studies include devel- vides only about one-third of the opment of control sources for pow- 2. muscle's total excursion. ered wheelchairs, and evaluation of Restoration of Upper Extremity Soft tissue resection is performed the therapeutic effects of functional Function through Tendon frequently from around certain electrical stimulation in gait. Transfer muscles in these procedures . Our Principal Investigators: data show that the result of the dis- 1. P. Hunter Peckham, Ph . D. section generally is to increase the Restoration of Upper Extremity Alvin A . Freehafer, M .D. excursion in both passive length- Function through Functional ening and active shortening . For the Electrical Stimulation Tendon transfer provides a viable means of restoring motor control to brachioradialis, the dissection ap- Principal Investigators: paralyzed limbs . Proper surgical proximately doubles both the active P. Hunter Peckham, Ph . D., procedure requires that the avail- and passive excursion (i .e., a 200 and Michael W. Keith, M.D. able muscles for transfer be identi- percent increase), while for the Pronator teres the increase is less These studies are the core area of fied, the potential functional loss (approximately 35 percent) . Assess- research in the center . The purpose due to altered anatomy be estab- of the project is to develop and lished, the properties of the trans- ment of length-tension information provides quantitative measure of the evaluate systems employing FES to ferred muscle be measured, the re- proper length for reanastomosis of provide control of paralyzed mus- sulting new function at surgery be the tendons . The shape and peak of cles . The systems developed pro- observed, and the postsurgical the curve indicated the length at vide control of lateral prehension training and care be carefully fol- which maximal force is generated and release or palmar prehension lowed . All aspects of this problem and the force decrement with and release. Seven quadriplegic are being investigated in order to . Thse characteris- subjects with C5 or C6 level motor provide improved methods of ten- changing length tics provide the surgeon with pre- function are presently involved in don transfer. cise information regarding the force- outpatient evaluation of these sys- The primary emphasis of this generating properties of the mus- tems. Patients from spinal injury study has been on intraoperative units at both the Cleveland Veter- monitoring of muscle properties cle, which otherwise must be esti- ans Administration Medical Center during electrical stimulation . To mated . These data are critical in two phases of the surgical procedure: and Highland View Hospital are in- date, measurements have been first, they allow one to determine volved in these studies. These stud- made for the excursion of 61 upper ies are being performed in conjunc- extremity muscles and the length- which muscle should most appro- tion with the VA Rehabilitative tension characteristics of 44 of these priately "motor" a given function, Engineering R & D program, and in 41 subjects. and second, the form of the length- the current status is detailed else- These studies have enabled us to tension curves assists one in deter- where in the Bulletin (see "Devel- determine properties of the muscle mining the proper length at which opment of Upper-Limb Orthoses which are critical in the final results Employing Electrical Stimulation" of the surgical procedure . First, ex- 'Direct measurements of forces and ex- under VA RER&D Service Pro- cursion measurements provide in- cursions voluntarily generated via cine- grams) . The work pursued in the formation on the total physiological plasty tunnels in human muscles have area of functional electrical stimu- range of a muscle. Excursion is ob- also been reported (e .g ., 3, 4, 5, 6) .

168 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

tion, will continue. We are presently using biofeedback as a training aid, Bunnell !Kaplan and using e!aothoal stimulation both therapeutically (to retard adhesion p / p * p ~~moseot,d )xA formation and strengthen muscle) and diagnostically to evaluate sub- optimally performing transfers, to improve functioning of transferred muscles.

References 1. Bunnell S : Surgery of the Hand, 3rd Edition. Philadelphia, J . B . Lippincott, 1956. 2. Kaplan EB : Functional and Surgical Anatomy of the Hand, 2nd Edition. Philadelphia, J . B . Lippincott, 1865. Brachioradialis Flexor p mxm Flexor Pronator Palmaris 3. Bethe, Albrecht : Physiological As- roxuCarpi * s oignvmm Teres Longus pects of the Construction and Func- Radialis Longus cupo/mialis tioning of the Voluntarily Movable (ring finger) Artificial Arms . Chapter in F. Sauer- MUSCLE bruch and C . ten Horn : Die Willkur- liche BewegbamkOmmiche Hand (The Voluntarily Movable Artificial Hand), Vol . 2 . Berlin, Springer, 1923. See also a series of papers by BO- Bethe which appeared in the K8unoh- ene, Medizinische Wochenschrift (Munich Medical Weekly)—No . 45, Bunnell pp . 1577-1579; Kaplan November 7, 1916 ' undixsecmu No. 31, July 31 ' 1917, pp. 1001-1003; . 16, April 22, 1921 . pp/47o-4n1. Dissected ' AAElPHP No See also Albrecht Bethe and Her- mann Kast, Synergische und rezi- poke Innervation antagonistischer Muskeln nach Versuchen an Beobachtungen Ober mm Reaktionszeit . In POuga,'sA,uh. Physiol ., 194, pp . 77-101, 1922. 4. Meyer, Karl : Die xxuoknmmnesavo, 2O- bmvh-Onn,ivue, und der Kraftver- brauch xunmUohe, Hmndo und Arme (The Muscular Forces of these with Sauerbruch Operations and the Strength Utilized by Artificial Hands and Arms) . Wiesbaden, Bergmann. Extclsor Extensor Extensor Also Berlin, Springer . 1920. Carpi Carpi Digit i 5. Inman VT, and Ralston HJ : The Me- mm/aox ulna//o Quint chanics of Voluntary Muscle, Chapter Longus 11, pp . 296-317 . In P . E . Klopsteg and MUSCLE P. D . Wilson, et al ., Human Limbs and their Substitutes . Nev, York, Mc- FIGURE 1. Graw-Hill, Excursion of muscles of the forearm as compared with studies of Bunnell(l) and a new bibliography : Hafner, 1968. Kaplan(2) for (a) flexor and (b) extensor musculature. 6. Taylor CL : Control Design and Pros- thetic Adaptations to Biceps and Pec- toral Cineplasty, Chapter 12, pp. 318-358 . In P. E . Klopsteg, et al., the tendon should be anastomosed tion . In that way the function of the as in Ref. 5, above . at transfer. transfer can be observed, and mod- Beothoal stimulation of the para- ification can be made if necessary. lyzed muscle provides the surgeon The method provides a rapid viouul with a unique method of assessing assessment of the operation of the the results of the tendon transfer. transfer. Before closure of the skin, the In the next period, these studies transferred muscle is excited with a as well as studies of methods for stimulus which is adjusted to pro- preoperative analysis and postop- vide a weak-to-moderate uontrao' erative care, training, and evalua- 169 Bulletin of Prosthetics Reseam*BPR 10-34(V~17 No . 2) Fall 1980

3. One patient having spastic hemi- studied . Apparatus has been con- Control of Abnormal Muscle Con- plegia has shown some beneficial structed for measuring neuromus- tractions effects of long-term use of the FES. cular function at the metacarpal- phalangeal joint of the thumb . (A Principal Investigators: Hie"toofirst stanoe^ separate apparatus for measure- Ronald R. Riso, Ph . D. was converted to a more normal "hoel strike first" stance . This effect ment at the ankle joint is also being John T . Makley, M. D. was carried over throughout the developed .) day—but was totally lost when the A motor applies torque at the joint The objective of this study is to stimulator was not used for several and measures the joint angle and investigate the therapeutic effects weeks. It was then found that the torque. In order to ensure repeata- of Functional Electrical Stimulation improvement in his gait could also ble measurements, the initial torque (FES) in the control of abnormal be produced by having the patient and joint angle are held within a . As a model for muscle contractions receive FES from an exercise stim- nma!l range. After the initial condi- this we are studying the effects of ulator set to cycle on and off while tions are established, a test change FES of the penoneal norvo, given in the patient remained seated in a in angle and torque is delivered, synchrony with the swing phase of chair; 20 minutes use of FES per and the meohanioal and electromy- gait, on the walking function ofcer- day for 5 days per week was suffi- ographic responses are recorded. ebral palsy children having drop- cient to produce and maintain this Sovoral measurements are made at foot andbr ankle extensor spastic- result. These are ongoing studies. each initial torque and angle 1oal- ity. Because of the benefioial effect low oonotruution of ensemble aver- CUnioal gait analysis (performed shown for this pationt, other simi- ages of electromyographic re- y at the Cleveland VA Wediva! Center larly afflicted children will be eval- sponse . In addition, the dependence Motion Study Lab) (including foot- uated while receiving FES in the of the response on the value of the to-floor contact patterns, ankle joint "exercise" mode . In addition, about initial torque and angle will allow angles, and dynamic EMG's of an- 5 or 6 new patients will be added evaluation of the state of neuro- kle flexor and extensor muscles) is over the next year to the group who muscular function on different days being used to assess (I) to what ex- are receiving the gait synchronized and will help to evaluate therapeu- tent the dorsiflexion produced dur- FES. tic measures in subsequent studies. ing the period of application of the FES continues after the stimulation is turned off and (ii) whether apao' 4. 5. tioity of the ankle extensors can be Evaluation of Command Controller reduced by periodic application of Abnormal Motor Control Development and Evaluation . Each the FES to the ankle flexors Principal Investigators: Principal Investigators: patient is evaluated on uevarol oc- Patrick E . Crago, Ph . D. P . Hunter Peckham, Ph . D. casions : initially to obtain baseline George H . Thompson, M .D. Dennis Roscoe, Ph . D. performance, and subsequently at Michael W . Keith, M.D. testing sessions when gait parame- The objectives of these studies ters are measured before, during, are to characterize voluntary and in- The purpose of this project is to and after a 20-min period of use of voluntary mechanisms of motor develop control techniques which the stimulator to provide informa- control in patients with movement enable disabled patients to control tion about effects from short term disorders, and to uomthis character- external assistive aids and devices. use of the FES . Patients take the ization of motor control to evaluate The studies are focused on control stimulator home with them for daily the effectiveness of different treat- techniques that provide viable sin- use and return, for evaluation of the ments. In the coming year, experi- g le and two-deg ree-of4reedom pro- effects of long-term use, at 2-week mental techniques of measuring the portional oontrol sources for high- intervals for the first month and at separate contributions of muscle level opinal cord injury patients, and one-month intervals thereafter. moohanioal prnportioo, stretch re- their evaluation in conjunction with For the seven patients who have f!exou, and voluntary reactions to the control of mobility (primarily the been teoted oevera!bmonfor^uhort the total response elicited by an ex- powered wheelchair) and hand term usage" effects, the dorsiflex- ternal test disturbance will be de- stimulation systems. ion and eversion of the foot con- veloped and evaluated . The tech- This project consists of develop- comitant to the electrical stimula- niques that will be used have been ment of three command controllers tion has never been sustained once developed in recent years in studies using shoulder position, head pooi' the stimulator was turned off. Our of neuromuscular function in nor- tion' and myoelectric activity as the efforts to induce dorsiflexion during mal human subjects, and their ap- signal sources . These command walking that would endure beyond plication in disabled patients ap- sources were described in BPR 10- the period of stimulation have thus peampromioing. 33. For the shoulder-position oon' far been largely negative, even for Studies will begin on the evalua- tro!. the ongoing process of trans- patients who have received stimu- tion of motor control in patients with ducer development (which is being lation for periods from 6 months to movement disorders . Initially, spas- completed) is intended to make fab- more than 1 year. tic cerebral palsy patients will be rication simpler, less expensive, and 170 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

more reliable . In addition, the de- Rehabilitation Engineering Center velopment and evaluation of Children's Hospital at Stanford mounting schemes which provide simple and stable donning of the 520 Willow Road, Palo Alto, California 94304 shoulder-position transducer are being completed. This technique of Maurice A . LeBlanc, Project Director control was developed primarily for control of a powered wheelchair, and a plug-compatible system has Survey on Controls a self-contained, battery-powered been developed to substitute this Objective—As a component of a system with a simple communica- controller for a oonvontional joy- comprehensive program for devel- tion light scanner in the top section stick controller. opment of new controls for assis- and an assortment of switches in The head-position control has tive devices for the severely dis- the bottom . The system features been developed as the command abled, a survey was made of a simple operation, a brightly colored controller primarily for the func- sample (200) of consumers, clini- display and audio output, and it will tional stimulation systems . The po- cians, researchers, and manufactur- be approximatley the size of an ot- tential of this device as an alterna- ers of assistive devices and con- teohouaoo. tive control technique for the trols. powered wheelchair is also being Progress—One prototype has been investigated . Progress—The survey has been made, and a second prototype is completed and results published in now being designed, based on com- o nnonograph tit!ed ^Aoa000mentof ment and evaluation of the initial Needs for Controls and Interfaces to design. For additional information, Operative Assistive Devices for the contact Ms. Margaret Barker, MS, at Severely Disabled" . It is available at the above address. no charge from Mr . John Preston, Jr. ' M .S.W ., at the above address. Controls Simulator Objective—This task started initially Catalog of Controls to utilize a computer program to Objective—In order to fulfill some evaluate a patient's ability to mas- of the identified needs, a catalog of ter proportional electric wheelchair controls, titled "Controls Reference controls. Software is used for the Catalog to Aid Physically Limited evaluation rather than time-con- People in the Operation nfAooiutive suming and expensive hardware. Devioon^haoboondenignod. The expanded objective is to test In the recent survey, 99 percent of patients with the aid of a CRT dis- consumers and clinicians who re- play, before deciding to invest time opondodfo!t that there is a lack of and money in providing hardware— information dissemination regard- much as a driving simulator may be ing new controls that are commer- used to teach/screen for automo- cially available. biles. The Controls Reference Catalog is intended to be used as a reference Pnngresm--The present system con- by people involved in the use or sists of an Apple II computer with provision of assistive devices. color graphics and a disc drive, used with custom-made controls to fit the Progress—The Catalog of Controls patient . Three programs have been is uomp!oted, published and avail- developed for computer control test. able at no charge, from Mr . John Program One places a dot on the Preston, Jr ., M.S.W., at the above video monitor that can be moved address. right and left with one control, and up and down with the other control. Control Abilities Evaluator This program is used to position Objective—The objective is to de- the controls in relationship to the sign and build a low cost, portable patient and to familiarize him with system to evaluate the control-us- the control. ing abilities of the disabled . The Program Two, "Break Ou't~' is a controls evaluator is envisioned as game with a paddle, ball, and wall 171 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

of bricks. The object of the game is ways to help alleviate this problem Speech Prosthesis and its "versa- to knock out all of the bricks with is to take graduate engineers with tile" controls and interfaces . The re- the ball . This game can be played interest in this field and give them search anddeve!opmontoftheVPSP with the X axis control or the Y axis practical experience . This can be has been funded by the NASA control. It tests the coordination and done through an internship pro- Technology Utilization Program via the endurance of the patient. gram similar to the mndioal model. Grant No . NSG–2313 from the Program Three draws a random It enables a trained engineer to ob- NASA-Ames Research Center . Two maze on the ooreon, and the contain clinical experience in many consultants on the NIHR Grant are trols move a dot up and down and areas of the field. being used in the clinical evaluation right and left . The object of this pro- A Stanford engineering graduate of the VPSP. The NIHR component gram is to move the dot through is nearing the completion of this is an important complement to the the maze without bumping into the first internship . He has spent 2 total project. walls of the maze . When complete, months with Communications/Con- the computer prints a score related trols Service, one month in Tissue to the number of the walls that were Trauma Son/ioo, one month in Seat- Progress--ThuVPSP has been eval- bumped as the patient steered his ing and Mobility Service, one month uated with a clinical protocol on course, and time needed to travel in Orthotics, and another in Pros- five patient subjects and tested in- the course. thetics. Arrangements have been formally for feedback with several For addidonal information, con- made for him to spend a month in other non-vocal people . Results tact Ms. Margaret Barker, MS, at the each of the following Rehabilitation were very encouraging . Speed of above address. Software is avail- Hospitals : Santa Clara Valley Medi- speech using the system ranged able. cal Center, Ralph K . Davies, and the from 4 words/minute with a single Spinal Cord Injury Service at VA switch control and 30 words/minute Temmm Evaluation of Device Effec- Medical Center, Palo Alto. with a keyboard control . Plans are tiveness being made to interest manufactur- Objective—In order to develop a Progress—A second o!inioal intern- ers in making it commercially avail- clinical evaluation model to be used ship was planned to start 10/1/80 for able and/or using the technology to prospectively in the assessment of 12 months. For additional informa- improve state-of-the-art of speech new controls, a retrospective study tion, contact Sandra Enders, O .T.R., aids. on Rehabilitation Engineering Cen- at the above address. For addibonal information, con- ter patients has been conducted . The tact Mr . Maurice LeBlanc at the 198 study-participants received rec- Versatile Portable Speech Pros- above address. ommendations involving a signifi- thesis cant oontrol and/or interface for a ObObjective—The task is to clinically major mobility system. evaluate the Versatile Portable The basic criteria for assessment were : 1. Device utility : were they working ; to what extent? Rehabilitation Engineering Center 2. Consumer satisfaction : were Smith-Kettlewell Institute of Visual Sciences they meeting the person's needs/ex- pectations? 2232 Webster Street 3. Goals attainment : were they San Francisco, California 94115 achieving their prescribed goals? 4. Life style change. Arthur Jampolsky, M.D ., Project Director ; John Bmmbyn . Co-Director; Cost and time factors were also and Deborah Gilden, Ph . D. analyzed . The study evaluated technical aids within the environment The first half of 1980 has seen the Orientation and Mobility where they were most frequently reorganization of our Rehabilitation used (home, aohoo!, job, etc .) Engineering Center after Dr . Law- Basic research . Our laboratory re- rence Scadden, our former Director, search into the roles of echo loca- Progress—The study has been com- took up his new post in Washington tion in mobility have borne fruit in pleted, published and is available at D .C . Our Center is now directed by results which confirm the superior- no charge from Ms. Sandra Enders, Dr. Arthur Jampolsky, who is also ity of steel versus nylon cane tips in OTR, at the above address. Director of the Smith-Kettlewell In- this respect . In the experiment, the stitute . He is assisted by Co-Direc- subjects (who were six blind men) Clinical Internship tor Dr. John Brabyn, and Associate had to state whether they perceived Objective—In the field of Rehabili- Director Dr . Deborah Gilden. an obstacle or not, while tapping tation Engineering there is a short- Research progress during the re- their cane on a concrete block set in age of experienced people. One of porting period has been concen- front of them . The results showed a the quickest and most cost-effective trated in the following main areas . significant difference between the 172 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

steel-tipped and nylon-tipped cane tunya ' mathematical and spatial and processing of data in our ex- conditions. puzzles, oto, the toy has the poten- periment to establish optimum pa- tial to make learning a pleasurable rameters for solid state flat-panel Talking Signs . During this report- activity for the visually handi- displays in low vision reading ap- ing poriod, further progress was capped. plications . In the experiment, car- made on a talking signs orientation ried out using 20 low vision pa- Vocational Aids system for the blind . The talking tients, the effects on reading speed signs transmitters (which are placed One of the most nu000aaful proj- of magnification, screen size, con- at locations of visual signs) have ects in this category has been the trast, and word length were inves- been redesigned and now consist of auditory oscilloscope, an adapta- tigated . It was found that contrast modular plug-in units . A contract tion for a normal Tectronix oscillo- was the most critical parameter, and was obtained to inuta!l a demon- scope which enables access to the acceptable values for all the varia- stration talking signs system in the display by blind users . The device, bles were established. Mary Switzer Building in Washing- which displays the vertical position A review of currently available ton D.C. of a cursor on the oscilloscope trace flat-panel display technology is now as the pitch of an auditory tone, has underway, with a view to selection Collapsible Cane . Work has com- been packaged into a circuit board of an appropriate display medium menced on fabrication of a proto- which fits inside the standard oscil- for a portable electronic magnifier. type collapsible, rigid long cane . A loscope mainframe. system of telescoping tapered glass- Several prototypes of the device Training fiber-reinforced sections has been have now been built, and have en- In addition to our existing pro- devised, in which the extended cane abled blind persons to obtain em- gram for training engineering stu- is held together by friction, and has ployment . One of the oscilloscopes dents in sensory aids research, a a rigidity similar to a normal single- is being used by a blind test tech- new facet of training has been resection long cane. nician at Telesensory Systems In- cently added to our Center . Under corporated, Palo Alto, while another the new program, technical training Educational Aids is being utilized by a blind techni- is provided for blind individuals in- The present reporting period has cian at Hewlett Packard incorpo- terested in the applications of tech- seen the completion of the first pro- rated. In each case the oscilloscope nology . The program, which is a totype of our microprocessor-based is essential to the person's job, and combination of a research project oduoadonol aid for blind and visu- the field evaluation data obtained and an educational service, is aimed ally impaired children . This new de- from these examples will be used to at investigating and disseminating vice, which takes the form of an improve future versions of the de- new ways in which blind and visu- vice. electronic game, incorporates suffi- ally impaired persons can partici- cient flexibility to be used for a wide pate in the electronic trades and Deaf-Blind Communications variety of learning tasks. professions, which are rapidly ex- Whereas the tremendous number Our Center continues its associa- panding areas of employment. of microprocessor-based toys now tion with Telesensory Systems, !n- Initially, attention is focusing on found on the consumer market oorpuraU»d, on the TeleBraille proj- the development of devices and nearly all use visual displays, our ect. This research effort is aimed at techniques to improve soldering and new device uses the same technol- the production of a deaf-blind tele- circuit board construction tech- ogy applied to the tactile and audi- communications system, providing niques which can be utilized by blind tory senses . In its initial form, the access for deaf-blind individuals to individuals. front panel of the toy presents to the telephone. We look forward to exciting re- the child a number of manipulative The laboratory prototype version sults from this program ; one tasks, such as replacing a fuse, of the device has completed an "Graduate" has already obtained turning on switches, opening evaluation phase at the Helen Keller employment as an electronic tech- !atohao, doing up nuts and bolts, National Center for Deaf-Blind nician at Hewlett Packard, Incorpo- etc. In one of a variety of skill lev- Youths and Adults, and Telesensory rated. els, the user races against the de- Systems, Inc ., has obtained a grant vice's internal clock to complete all for further development to the pre- Information Dissemination the tasks in sequence . Feedback is production prototype phase. Our Center has been actively con- obtained by musical scales and Another development of benefit tributing to the establishment of the tunes. to deaf-blind individuals has been a Abledata computer-based informa- The new device has been found tactile version of our successful light tion system being developed by the to be highly motivating, to both vis- probe . Prototype examples of this National Institute of Handicapped ually and physically handicapped device are currently undergoing Research. children as well as sighted individ- evaluation. Another facet of information dis- uals. By replacing the present front semination which has been panel with modules containing dif- Low Vision Research launched during this reporting pe- ferent tasks, such as matching 1ox' We have completed the gathering riod is the Smith'Kott!ovvol! Techni- 173 Bulletin of Prosthetics Research, BPR 10~(V~17 No . 2) Fall 1980

cal File. This is a quarterly technical Rehabilitation Engineering Center publication for blind and visually Moss Rehabilitation Hospital—Temple University impaired readers who are interested in current technology. The first —Drexel University issue of the magazine has now been Philadelphia, Pennsylvania 19141 published, and contains articles on soldering techniques for blind por- Gordon D. Moskowitz, Ph . D., Director, V . Theerasakdi, M .D., Medi- oono ' useful electronic construction cal pro)oota, and other aspects of electronics and sensory aids of interest This report (Status Report 111/80--6/30180) is a followup on the re- to the blind. search and development reported in BPR, Spring 1980 issue. The publication is available in large print, Braille, and talking book forms. Subscription information can RESEARCH AND DEVELOPMENT ally by footswitches taped to the be obtained from the Editor, Bill bottom of each shoe. Gerrey, at the Rehabilitation Engi- Phase-Dependent Reflex All patients showed a significant neering Center . We intend to use Reversals in Controlling difference in hip or knee motion this publication both as a means of Locomotion after electrical stimulation (p .-O.05). direct dissemination of up-to-date This occurred with a minimal technical information to interested Responsible Investigator: Rebecca L. Craik, M .S.P.T. change in walking velocity which blind persons, and as a forum for suggested that the stimulus altered discussion and feedback from users (This is a continuing project : see the pattern of movement rather than of sensory aids. BPR 10-32, Fall 1979, pages 291-292, the speed of walking . A larger sam- for description and objectives .) ple size is presently being collected. "Normal" locomotor function is A computer program has been rarely recovered by patients with developed to examine whether the hemiplegia secondary to a cerebral above-mentioned change in the in- vascular accident (CVA) . For exam- dividual biomechanical parameters ple, the inability to adequately clear is functional in terms of limb clear- the ground with the involved limb ance . Using the output of o!nutro' during the swing phase of gait often guniometero . the program calcu- contines despite correction with an lates relative displacement of the ankle-foot orthosis (AFO) . The pur- knee, ankle, heel, and toe—from the pose of this study is to determine if hip. (A decreased vertical distance electrical stimulation applied to the between the hip and toe during skin over the terminal distribution swing indicates an improved limb of the sural nerve in the hemipar- clearance .) etic leg would alter swing-phase A stick figure has been developed performance. using these data and assuming a Data were analyzed from a sam- constant hip height (Fig . 1) . This fig- ple of seven patients with hemiple- ure shows three sequential strides gia secondary to a CVA . Selection of control data collected from the criteria for these patients included hemiparetic limb on the left, and the following : (i) independence in three sequential strides of the same ambulation with maximal assist- limb's performance is depicted on ance of a standard J-cane or quad the right during delivery of electri- cane and an AFO, (ii) passive ankle cal stimulation at the time of heel- dorsiflexion to neutral, and (iii) off. The effect of the stimulus is mentally alert,and cooperative. seen during the intorvel before foot *Subjects walked until an average contact (at the beginning of each of of 16 steady-state control strides the three strides in the figure) . Al- were collected. The patients then though there was no obvious walked an average of 16 strides change between the control and the while receiving a nonpoinful stimu- stimulus condition for this subject, lus to the suml nerve area at the close examination of the foot shows time of heel-off. Walking speed was that the forefoot is not as far "be- measured using a tachometer, uaA- low the !evol of the floor" during iuul hip and knee motions' were the stimulus condition . measured using bi!ateral o!motrogn' niomatmm' and heel and toe contact and release were detected bilater- 174 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

of the VOR has been clarified . Sev- Effect of Altered Sensory poneofthiastudyiutoexaminnthe eral nnrmal subjects have been Input on Stair Descent effect of visual disturbances on the tested in this new protocol and the Responsible Investigator: motor performance exhibited dur- data analyzed. Preliminary results William Freedman, Ph . D. ing stair descent. show that thoC8R and VOR do co- The developed instrumentation exist—and that their effects are dis- (This is a continuing project : see ino!udeo a uavdboard ^noom^vvh000 tinct and separable. BPR 10-32, Fall 1879' pages 296-297, excursion (±40 .6 cm) is produced It is hoped that these data will for description and objectives .) by a change in the subject's vertical provide the information needed to For the disabled and geriatric position through a servo system. determine the funotional meaning population, the task of descending This room surrounds three steps of the cervico-ocular reflex . Toward stairs is often difficult and danger- whose height can be adjusted to be this end, we have received the co- ous. Many neurologically disabled 20 .3, 30.9. 40.6 cm . Instrumentation operation of several departments of patients demonstrate viuua!-pomop- used to collect data allows mea- otolaryngology in sending to us for tuol problems as well as motor con- surement of descent time, vertical testing those patients who have trol problems secondary to the oon- acceleration, muscle activity, ankle been diagnosed as being "without trol nervous system insult ; a vast and knee joint range of motion, and vestibular function ." So far, we have majority of the geriatric population ground reaction forces (Fig . 3). tested two patients who showed no demonstrates a ,decreased visual Subjects were asked to descend vestibular response to caloric stim- acuity . However, the available !iter- these stairs under various condi- ulation ; i .e ., hot and cold water ap- aturoto describe the interaction bo- tions : (i) naturally and comfortably, plied within the auditory canal. tweonthm intact or impaired visual (ii) blindfolded and uanware of step Because these patients function system and dynamic lower limb height, (iii) wearing a collar which very well, it has been theorized that performance is limited . The pur' precluded stair visualization during the nonexistent VOR is replaced by the COR. There is some evidence that this may be true from experiments on monkeys . In man, however, the plasticity of the COR-VOR system still must be proved to exist.

FIGURE 2. Instrument for Clinical Analysis of Gait. The control box contains digital circuitry and a microprocessor to generate the multiplexor coding, to store switch closure and release times, to operate the lighted footfall display, and to perform the computations and printing of the results. Four control buttons allow the operator to begin the acquisition of data, FIGURE 3. to terminate it, to print the data, and to This figure illustrates the instrumentation worn by each sub- reset and clear the device in preparation ject during this experiment (Effects of Altered Sensory Input for another pass by the subject . on Stair Descent) .

175 Bulletinof Prosthetics Research, BPR 10-34 (Vol. 17 No . 2) Fall 1980

Tii //Pilk\\\\\\ a.

\I\//0''\'\'\ \a\ll\ \ )//) \ //// \9\' /8/n A\\ ///)'I''gV\\\\ "''

FIGURE 1. The involved limb's performance in three sequential strides is depicted prior to stimulation (3 examples at left) and during stimulation (at right) . This stick figure was developed using the output othe electrogoniometers . Sampling interval was 60 ms . Black solid triangles indicate time of foot contact . Solid black disc in right-hand column indicates times of stimulus.

Acquisition of Transient prot000l and the subsequent analy- sensitive segmented mat (Fig . 2) and Visual Information : Implica- sis. Also, software has been written storing both initial-contact and con- tions for Mobility which makes analysis quicker and tact-release times for each seg- Responsible Investigator: easier. The electronic hardware has ment. The ovara!l scan time is William Freedman, Ph . D. been tested for frequency response longer (40 msec), but further work and linearity. on the operating program could (This is a continuing project: see Currently a protocol is planned shorten this toward the original 20 BPR 10-32 ' FaU 1878' pages 295–29S' which will determine the visual field msec . The new printout tabulates for description and objectives .) of acquisition with no eye move- both On and Off times, and includes The protocol—which includes ro- ment and no head movement . This the provision for adding an asterisk tation of the posture platform ran- will represent the baseline with alongside points which are deleted domly between ±20 deg as well as which all previously collected data by editing of the raw data before random presentation of target po- and results can be compared . The computation. The programming task sition and of target duration—has experiments will be conducted on for automatic data-reduction has been run on 10 normal subjects. normul subjects using both dot and begun and appears to be feasible Dot and character target presenta- character presentations . Also within the limitations of the present tions were used for both head planned is testing of patients, now microprocessor capability. movement and no head movement that baseline normal data have been The first version of the gait mat conditions . As described in predetermined for all protocols . Fi- was exhibited at the Toronto Inter- vious reports, eye and head move' nally, reports are now being pre- national Congress of Rehabilitation monto' response and response time pared describing results thus far Engineering on June 16-21, 1980 ' were the data collected . These data obtained. and numerous inquiries were re- have been analyzed by computer ceived. and are now being compared with data from previous protocols. Instrument foer Clinical The head-movement measuring * Analysis of Gait Cervico-Ocular Reflex Effects device has been improved, and the Responsible Investigator: in the Presence of the above experiments have shown it Don Taylor, B .S.E.E. Vestibulo-Ocular Reflex to be much more comfortable with Principal Investigator: less restriction of movement than (This is a continuing project : see William Freedman, Ph . D. the previous method . Also, addi- BPR 10'32 ' Fall 1979, page 301, for tional computer software has been description and objectives .) (This is a continuing project: see written to enable a more detailed The replacement of the original BPR 10-32, Fall 1979, page 294–295, scrutiny of calibrations. This analy- electronic hardware package with a for description and objectives .) sis has demonstrated that postcali- microprocessor unit is almost com- Since the last reporting period, bration after each slide is unneces- plete, including the software for op- the methodology of measuring the sary, which will simplify both the erating the 13-foot-long preoaure- effects of the COR in the presence 176 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

ment is acceptable, but problems will occur if the electrode fit in the socket is not air-tight. A prototype of the actuator has been constructed . It consists of a pneumatic cylinder across the knee joint, a pressure vessel strapped to the shank part of the pylon, and a series of two-way valves mounted on the anterior of the shank below the knee. Transducers, necessary to feed back information on the state of the actuator for the control algo- rithm, have also been incorporated. These include : pressure transducers in each side of the cylinder and in the vessel, and a linear po- tentiometer to measure piston position relative to the cylinder . All electronics and computer hardware is located in a fixed equipment rack connected to the prosthesis via um- bilical lines through an overhead trolley . Bench testing of the hardware is currently being performed; this is to be followed by testing with an amputee.

FIGURE 4. This figure displays characteristic analog data collected when Lower-Limb Prosthetic the subject went from the top to the second step during stair Components walking. Responsible Investigator: Charles Prithamm' C.P.O. descent, and (iv) with the room conflict which was set up also (This is a continuing project : see moving up or down during stair de- caused the EMG activity propana- BPR 10-33, Spring 1980, page 134, scent. 1nryto contact to be reduced. for description and objectives .) Fourteen healthy subjects volun- Data analysis is now being com- Design work on a suitable man- teered to participate in this experi- pleted to determine if the various ually locking endoskeletal knee, as ment Selected subjects ranged in test conditions altered the step- well as o!ternotivee, continues . Ef- age from 18 to 35 years, in height down motor performance. forts to procure a British designed from 1 .57 to 1 .75 meters, and in knoo of thio typ* (tho ^Simp!ox^ weight from 49 .4 to 81 .6 kilograms. knee by Hanger) have been initi- Figure 4 shows ohorouieriod : ana- Development of Myoelectric ated, and despite delays in ship- log data collected when the sub- Knee Control for Above-Knee ment it is expected that two of these jects were asked to descend the step Prostheses units will soon be available . Herbert "naturally and comfortably " De- Responsible Investigator: Thompson (of Blatchford's, U .K.) has picted in this figure is the swinging G. Moskowitz, Ph . D. stated in casual conversation that a limb's performance from the irut to variation of the Blatchford Modular second step. (This is a continuing project : see Assembly Prosthesis (MAP) with Preliminary results show that BPR 10-32, Fall 1979, page 299, for manual-locking knee is comparable when the subject is blindfolded the description and objectives .) in weight to the Hanger unit, and muscle activity (EMG) preperoio py A suction-type socket was con- consideration is being given to ob- to contact with a lower step !ovn! is structed into which holes were cut taining one of these units for in- reduced with respect to the EMG to accommodate EMG electrodes . A spection, also. activity during comfortable steps. series of experiments was per- Considerable effort has been ex- This means that larger forces must formed to determine hole locations pended by several members of the be absorbed within the bony struc- such that the accuracy of the pat- staff in pursuit of a concept ad- ture of the lower limb. tern classification scheme would be vanced by the medical director of Similarly, when the surrounding preserved . Results indicate that the the REC : it is the use of the Otto room moved, the visual-vestibular current socket-electrode arrange- Bock 3K9 knee unit in fabrication of 177 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

an exoskeletal polypropylene AK shaped and smoothed . Efforts will mentation in facilitating the devel- prosthesis. While it is attractive in continue to develop and evaluate opment of motor skill . It is hoped some respects, there remain many the two methods. that the results of this investigation doubts about this concept . The It is firmly believed in this quarter will eventually assist others in the prinoipal question is about the that the best cosmetic cover is in- development of more specific appli- physical strength of the prosthesis adequate without a suitable pros- cation of feedback techniques and and steps have been taken to per- thetic skin to preserve its integrity. design of rehabilitation equipment. form physical testing of such a The acrylic-latex skin developed un- The Knee Angle Monitor (KAM) is prosthesis. Standards and proce- der sponsorship of the VA is one a joint-position feedback device de- dures (derived from !SPO-dova!' solution to this problem. Another signed to provide immediate audi- opyd standards) for testing have solution is possibly to be found in tory information to the patient about been formulated, and it remains to the use of a urethane elastomer, the relative movement of the knee find a suitable testing machine. Lynadure (1) available from Medical (1,2) . The device consists of two Working independently but in Center Prosthetics . After some ex- parts : a knee electrogoniometer, casual consultation with Michael perimentation a method which uses which detects angular position, and Wilson, C .P.O. (of Medical Center Lynadure thinned more than rec- a oonuol box. The auditory infor- Prosthetics, Inc ., 6955 Alameda ommended and brushed into cos- mation can be displayed in two Road, Houston, Texas 77021> ' and metic hose and nylon hose has been forms : (i) a tone which increases or from different starting points, simi- developed . It is intended that this danroaoen in pituh oe the "*!gon^ lar procedures for the foaming- prosthetic skin will be used with the rotates (action feedback), or (ii) a in-place of a urethane foam cover above described cosmetic covers to single high-pitched tone that can be about the below-knee prosthesis counter the problems associated placed at any desired angle (termi- have been developed . Michael Wil- with current techniques of cosmetic nal feedback) . In use, the electro- son has demonstrated a similar pro- restoration. goniometer is fastened to the lat- cess for the forming of a cover for Reference eral side of the knee with rubber an above-knee prosthesis as well. straps . In this position, it senses For the below-knee prosthesis, the 1 . Wilson, MT (CPO) : Clinical Applica- tion of PTV Elastomers . Orth & Prosth, flexion and extension movements result is a cover that is reinforced 33(4) :23-29, December 1979. of the knee. on the inside and intimately in con- Preliminary work using the KAM tact with the surface of the ondo- only, during ambulation with both uka!otal prosthesis . It only remains The Relationship between normal and hemiplegic subjects, for the outside contour to be shaped Tibial Torsion and Knee Stress produced varying results inthosub- and sanded smooth . Continued im- ject's ability to alter the motor pat- Responsible Investigator: provements in the formulation of tern to match the action auditory Thomas Cook, M.S.P.T. the urethane foam have been made feedback (1). by Medical Center Prosthetics and (This is a new project .) The purpose of this project is to recently a new version, Biothane A study is underway to examine compare the effects of two kinds of 360. has been introduced . The fab- the relationship of tibial torsion to artifioial auditory feedback, action rication technique facilitates the excessive frontal plane moments at and terminal, on various knee joint process of shaping a foam cover by the knee joint . Eight subjects with positioning tasks. It is anticipated rendering a very accurate internal abnormal tibial torsion and 21 nor- that the results of this study will shape with mininnal work, it rein- mal subjects have been tested in provide definitive guidelines for the forces the cover from the inside (this the gait laboratory . The data are use of the Knee Angle Monitor latter point may make one piece AK currently being analyzed. (KAM) . The project is divided into covers considerably more practical), two parts: and it is compatible with any of the Phase I : a comparision of the ef- *ndnoko!otal systems. A Comparison of the Effects of Ac- fects of the two kinds of auditory Six PTB fairings manufactured by tion and Terminal Feedback on feedback on nonambulatory knee- Charles A. B!atohfondand Sons, Ltd ., Knee-Joint Positioning Tasks joint positioning exercises in a nor- and intended by them for use with Responsible Investigator: mal population. the British MAP, have recently been Cmnm!Lo!par, LPT Phase II : utilizing orthopedic and received . These fairings are Plasti- neurologic populations and includ- zote cones intended to be thermo- (This is a new project .) ing a comparison of the effects of formed, with vacuum assist, about Design of auditory feedback the two kinds of auditory feedback the structure of an ondooke!mtal be- equipment has proceeded with little during ambulation training in or- low-knee prosthesis . The result, as investigation as to the validity of thopedic and neurologic popula- described above, is a cover that is the various sounds utilized as per- tions. in intimate contact with the pros- formance information . This investi- The work with 24 normal subjects thesis. It is achieved with consider- gation is intended to determine the in Phase 1 has been completed. ably less mess and bother, and the relative efficacy of two methods of Subjects were randomly assigned resulting cover is quite easily providing nonvorbal auditory aug- to two groups . Each group received 178 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

training on an exercise task with Below-Knee Amputee Gait: p!abon . Each patient was selected one of the forms of auditory feed- A Comparision of Walkers and on clinical grounds for the use of back . Subjects practiced a joint Parallel Bars functional electrical stimulation to movement using the feedback and Responsible Investigator: the pornneal nerve in order to con- then tried to reproduce the move- Thomas Cook, M .S .P.T. trol the swing phase of gait. Thir- ment with no feedback. Accuracy of teen patients were initiated into the reproduction was measured to the (This is a new project .) study with three patients droppi ng nearest 0.5 degree . No significant A study was completed which de- out early. differences were apparent between scribed temporal and kinetic differ- A variety of etiologies included the two groups. ences in the gait patterns of 15 ger- cerebral vascular accident, cerebral Similar testing will now com- iatric below-knee amputees when palsy, multiple sclerosis, and spinal mence with orthopedic and neuro- these patients walked using parallel cord injury . Patients were nourolog- logic populations where the goal is bars and a walker . Results of the ically stable for at least 6 months or an increase in range of motion of study were presented at the confer- more prior to their entry into the the knee joint. ence of the American Physical Ther- study . An average of 40 minutes References: mpy Association and indicate that was required to instruct each pa- walking in paraUal bars causes ger- tient in the use and application of 1. Rehabilitation Engineering Center Progress Report No . 4 (1974-1975) p. iatric omputoouto exhibit a gait pat- the FES unit . To date, 27 phone 84 and 96-100, Moss Rehabilitation tern which is faster and more "nor- calls have been received by the Hospital, Philadelphia. mal" than ambulation using a project staff with regard to prob- 2. Reliability Testing of the Knee Angle walker, but which is also biome- lems or questions that the patients Monitor . !nnamal report Rehabilita- chanically more demanding on the tion Engineering Center March 1978 had during the period of study— Moss Rehabilitation Hospital, Phila- prosthetic limb. about 4 1/2 hours of telephone time delphia. was required by staff during the 6- month trial for the patients so far. Gait Characteristics Acquired dur- Examination of Gait Function The main concerns for these phone ing Ambulation Training Following Intrasynovial calls related to placement of the Responsible Investigator: Knee Injection electrodes and problems with the Rebecca Craik, M .S.P.T. Responsible Investigator: foot switch . Less frequent reasons Thomas Cook, M.S.P.T. for phone calls included battery re- (This is a new project .) plaoament, problems with various The purpose of this project is to (This is a new project .) connections of the unit, difficulty describe the acquisition of the gait A study is underway to describe with electrodes, requirements for pattern in patients being trained to the changes, if any, in selected gait more sandpaper and conductive gel, walk with a temporary or definitive parameters following intrasynovial complaints of thigh orampo, and skin above-knee or below-knee pros- corticosteroid injection of the knees irritation due to Velcro straps. thesis, and in patients with right or of arthritic patients . The selected A few additional appointments left hemiplegia secondary to cmro- gait parameters include bilateral were required to review placement bral vascular accident . This infor- measures of step length, step time, of electrodes with patients . One mation will be used as a control rate of vertical !oading, peak verti- particular patient required three ex- data base to compare with data from cal load, vertical impulse, and knee tra sessions (lasting several hours a similar group who will have var- range of motion. each) because ofu presumed place- ious feedback devices incorporated To date, four arthritic patients ment problem . Eventually it was into their training program . Instru- have been tested and some pnnto- discovered that biological fatigue of mentation used to collect data on ool adjustments have been insti- the ankle dorsiflexors and evertors walking performance includes the tuted . A1ota! of 20 patients will par- was resulting from prolonged usage. instrumented gait mat and the dual ticipate in this study. Compensation for this fatigue factor force monitor system . Data will be was accomplished by having the collected on chart recorders and re- patient rest for one or two minutes duced by hand. EVALUATION PROJECTS and then continue walking . This Parameters monitored include: provided an excellent response with average walking velocity, cadence, Functional Electrical Stim- the unit and revealed that the actual step length, single and double sup- ulation Systems placement site was good. port time, stance force, and loading Responsible Investigator: Comments by patients included rate . The patients will be selected N. Mayer, M.D. suggestions related to the desire to from the in-house population at have a smaller size of the unit for Moss Rehabilitation Hospital . To (This is a continuing project : see cosmetic purposes ; a change in the date, three patients, two with a be- BPR 10'32, Fall 1979, pages 301-302, color of Velcro strapping to accom- low-knee and one with an above- for description and objectives .) modate different seasons ; shorter knee prosthesis, have participated Astudy of0 months of usage in wires, and better ways to keep the in this study . a group of patients is nearing oom' electrodes in place . 179 Bulletin of Prosthetics nesearchBPR 10-34 (Vol . 17 No. 2) Fall 1980

the initial application of functional iS .EK,Boston, USA, 1978. variety of sources throughout the peronaul nerve stimulation . Data on 4. Waters R, McNeal D, Perry J : Exper- area for gait analysis . The objec- imental Correction of Foot Drop by the immediate effects of FES were Electrical Stimulation of the Peroneal tives of this demonstration project handled by means of analysis of Nerve . J Bone & Joint Surg 57-A- :8, are threefold : first, to utilize the gait variance consisting of a two-factor December 1975. laboratory facilities to provide data factorial design. useful to medical and paramedical Analysis of the data reveals that, paroonnol regarding specific pa- for the group as a whole, patients Evaluation of a Gait-Training tients ; secondly, to determine the were able to distinguish the two Technique in BK Amputees kinds of data and instrumentation anto of oomnnando ; namo!y ^vvo!k Responsible Investigator: which are most useful for purposes natura!!y" vorauo ^vve!k on faot ao Deborah Ryan, LPT, Rebecca of patient management ; thirdly, to poanib!o.^ With regard to the pa- identify questions about pathologi- rameter of muxinnol velocity, no sig- cal gait which are in need of further nificant difference was observed This is a new project. research. with FES compared to the runs There is some controversy re- During the past 6 months 24 pa- without FES. Patients were able to gan1ingtho manner in which a patients have been referred for gait walk at different average cadence tient begins ambulation with a analysis from 6 different institu- (p< .1) when given the different prosthesis . The purpose of this tions. Testing procedures and re- commands of "walk naturally" ver- study is to determine whether train- port formats continue to be refined. sus "walk as fast as possible ." There ing amputees to initiate the gait was no difference, hovvover, be- cycle with swing through ofthenon- tween the conditions with FES and amputated extremity will produce without FES as far as cadence is more equal bilateral step length Adaptive Seating Service concerned. The right step length when compared to initiating the gait varied as a function of the differing cycle with swing through of the Responsible Investigator: command speeds. However, left step prosthetic leg. Carol Leipw LPT length as well as left and right stride The sample to be used for this (This is a continuing project : see length were not influenced byfunc- study will consist of 40 patients with BPR 10'33 . Spring 1980, page 137, tional electrical stimulation, nor uni!ataral below-knee amputation. for description and objectives .) were they significantly different at Patients selected will range in age Over the past 2 years personnel different command speeds . When between 50 and 70 years and have has been involved with the evalua- the stimulation unit was turned on, no secondary diagnoses that will in- tion of wheelchair seating systems all patients were noted clinically to terfere with ambulation . The sam- developed at the University ofTen- have visibly improved dorsiflexion ple will be divided into two groups; na0000 REC . Through this projoot, of the ankle and clearance during one group will begin ambulation staff became involved as consult- swing phaa*, as well as having heel with the amputated limb swinging ants to the pediatric staff at Moss strike at initial contact of the stance first while the other group will be- Hospital . The duel purpose of this phase. All patients who had potho- gin ambulation with the sound leg project is to develop the service as- logioal inversion of the foot without swinging first . Step !ongth, cad- pect of providing adaptive seating FES were converted to a neutral or ence, and velocity will be calculated systems where oommoroial prod- even partially everted foot position using the instrumented gait mat. ucts are unsuitable, and to stream- when FES was turned on . Thus, Walking performance will be mea- line the fabrication process by the from a o!inical point of view, the or- sured on two separate occasions. use of new techniques. thotic goal of gaining ankle-foot The initial measurement will be one In the past 6 months, eight chil- oontrol during swing phase was day after receiving the pylon ; the dren have been referred who re- achieved. final measurement will be recorded quired specialized evaluation for the last week before discharge . Two References: seating, assessment of abilities to 1. Ship G, Mayer N : Peroneal Nerve patients have volunteered to partic- operate a power chair, or unique Functional Electrical Stimulation : For ipate in this project to date. fabrication . Recommendations were Whom? In : Proceedings for the Sixth made for six children suggesting International Symposium on External Contml of Human smrvmideo . Dub- the specialized use of commercial rovnik, Yugoslavia, August 1978. PATIENT/CLIENT SERVICES products or providing specific mea- 2. Experiment of the Warsaw School of surements and diagrams for build- Medicine Rehabilitation Department Clinical Gait Analysis Service ing . Direct fabrication was com- with Application of the LFEPB in the pleted for another two children. Rehabilitation of Hemiplegic Patients. Responsible Investigator: Further development of this proj- Clinical Evaluation of the Ljubljana Thomas Cook, M .S .P.T. Functional Electrical Peroneal Brace, ect is anticipated through the devel- National Academy of Sciences, (This is a continuing project : see opment of a seating clinic at Chil- Washington, D .C . 1973. 3. Alfieri V, Grillo VL, Merletti R : Gait BPR 10-32' Fall 1978, pages 305-306, dren's Hospital of Philadelphia in Timing in Normal and Hemiparetic for description and objectives .) which REC peruonnol are consult- Children and Adults, 4th Congress of Patients are being referred from a ants . 180 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

Patients who dropped out early in plegic gait "both in elegance and neutral, ability to perceive, respond the study had a variety of difficul- speed" when pnronoal nerve stim- to, and adequately tolerate stimu- ties with the mechanics of putting ulation was utilized . Alfiori . Grillo, lation—and absence of a cardiac on the unit. A certain amount of and Merletti (3) reported an in- pacemaker .) "gadget tolerance" is required to crease in natural cadence and in When a suitable patient was iden- follow through with usage . Ten pa- gait as a whole after only 1 to 2 tified c!inioaUy, the REC 2 Func- tients who did follow through with months of use of funotional electri- tional Electrical Surface Stimulator their device used the orthosis on a cal stimulation to the peroneal was applied to locate the best site full-time basis during the day for nerve. Waters, McNeal, and Perry of peroneal nerve stimulation for ambulation purposes. (4) measured gait velocity, stride producing balanced dorsiflexion. Analysis of the repair record of length and cadence at both com- Patients were ambulated a short each new unit produced byourRe- fortable and fast walking speeds in distance to evaluate and adjust the habilitation Engineering Center re- 13 patients and found an increase response during gait . After the in- veals that each unit used by pa- in these gait parameters after 6 tegrity of the response as well as tients during the 6-month study was months of stimulation. patient tolerance to stimulation were brought in for servicing at least The studies mentioned above checked, patients were brought to a once . One unit was brought in twice seem to support the idea that walkway to study the immediate ef- and one unit was brought in three chronic usage of FES results in an fects of peroneal nerve stimulation times . The amount of time spent improved gait performance beyond applied during swing phase . Each servicing and repairing these units the clinically obvious direct motor patient was instructed to wa!ko dis- was 17 hours . Common problems response of the peroneal nerve tance of 30 feet in sets of two com- included replacing batteries which which caused dorsiflexion of the mand speeds : (i) "walk naturally" had been sized incorrectly by the foot. However, the literature does and (ii) "walk as fast as p000Ub!o .^ patients, repairing foot switches and not specify whether the mere appli- Poronool nerve stimulation was ap- loose iaoko, replacing broken cation of FES is sufficient to cause plied to half the group during the switches, light-emitting diodes, and an immediate change in gait per- first set of commands and was not parts of the integrated circuits . Foot formance measures, or whether applied during a second set of com- switches, electrodes and cables long-term use of FES as an orthotic mands. The other half underwent were replaced in a number of units. device is necessary in order to pro- the reverse procedure (i .e., nostim- At the present time, it would appear duce a training effect which brings ulation during the first set of two that o!ininul usage of this FES unit about improvement in these per- command speeds followed by stim- requires the availability of an elec- formance measures . The objective ulation during the second set) . (This tronic servicing site. of the current study on peroneal procedure was adopted to eliminate FES is to determine whether effects of test order .) Evaluation Activities—In addition to changes in measures of gait per- Measures of maximum velocity, looking at the clinical reliability of formance occur immediately after cadence, step length, and stride our FES unit, we also conducted an the application of FES or whether length were made with and without evaluation of the effects of FES on long-term usage is necessary to de- the application of functional electri- various gait parameters—with spe- velop such changes. cal stimulation at both sets of com- cific interest in gait speed . Func- Twelve patients with uppe r mo- mand speeds. Cord connected to a tional Electrical Stimulation (FES) of toneuron lesions who had difficulty tachometer was attached to the pa- the penoneal nerve has been advo- controlling swing phase of gait were tient's belt by means of a safety pin cated in the literature as an orthotic studied . Eight patients had had a in order to measure velocity . The treatment for patients with upper cerebrovascular aooidnnt, two pa- analog velocity signal was recorded motoneuron syndromes with clear- tients had multiple sclerosis, one on a calibrated strip chart recorder ance difficulties (1) . Direct motor patient had cerebral palsy, and one and 200o 25 measures of the max- stimulation of the peroneal nerve patient had opinel cord disease of imal velocity in each gait cycle were causes dorsiflexion at the ankle dur- unknown etiology . All patients were averaged over the distance walked. ing swing phase, improves or elim- neurologically stable for at least 6 Dyed moleskin was applied to the inates dragging of the foot on the months or more . The main clinical huel and sole of the foot of each floor, and provides the patient with reason for patient selection in this shoe in order to stain a sheet of a heel strike at initial contact . The study was inadequate clearance with brown paper on which measure- literature also suggests, however, drag of the foot along the floor dur- ments of step length and stride thatp000neo! FES results in the im- ing some part of swing phase. length were made . An average of at provement of certain performance (Genorol criteria for selection in- least five to seven measurements in measures of gait both qualitatively clude the presence of upper moto- each run was used . Two precision and quantitatively . A 1973 study by neuron pathology with intact pero- stop watches were used to deter- the Committee on Prosthetic Re- noa! nerve function, ability to mine the time of walking 30 feet to search and Development (2) reports ambulate but with impaired swing derive cadence. that the Warsaw School of Medicine phase clearance, passive ankle Patients were studied under the found an improvement in hemi- range of motion to approximately above protocol immediately after 181 Bulletin of Prosthetics Research, BPR 10-34 (Vol. 17 No . 2) Fall 1980

EDUCATION AND DISSEMINATION search at the Engineering Center . Pre- bona' leader for a course on Prosthetics sented at Physical Therapy Depart- and Orthotics. The following papers by ment, Magee Hospital, Phila ., Pa. May members of the Center were presented: Allied Health Student 2, 1980. "An Instrumented Gait Mat" by Don Affiliation Program Craik, R. The Role of the Physical Ther- Taylor ; "Myoelectric Knee Controller for Clinical Coordinator: apist in Research . Presented to the AK Amputees" by Donald R . Myers and Department of Physical Therapy, Gordon xxouxowi/z ; ond ^Fun,tionu! Rebecca L. Craik, M .S.P .T. 5ohvvl of Allied Health, Temple Uni- Peronel Nerve Stimulation and its Im- versity, Phila ., Pa. May 17 and May 14, mediate Effects on Measures of Gait (This is a continuing project : see 1980. Performance" by L . Cohen, K . Turner, N. BPR 10'32' Fall 1379 ' page 303 . for Craik, R . Sensory Feedback : Rationale Mayer. previous mention .) and Treatment Application . Presented An nddidnnal paper "The Develop- The primary purpose of this pro- at Duke University, North Carolina, ment of an Engineering Service" by May 19, 1980. Serge Minassian, Director of the Engi- gram is to expose students to re- Craik, R., ooLhm ' A, Burke, T . Facilita- neering Service at REC #u, was ac- search methodology and its appli- tion of Movement by Afferent Stimu- cepted for publication in the Conference cation to the field of physical lation . Presented at APTA, Arizona, proceedings. therapy . The students are assigned June 18 ' 1980. 3. REcStaff Attends American Phys- ical Therapy Association Meeting . Re- to specific research projects and are Craik, n, Cook, T ., D'Orazio, B . Veho- hunsin Healthy Gait with Changes in becca Craik, L .P .T., Carol Leiper, L .P .T ., guided by individual project direc- Velocity . Presented at APTA, Arizona, and Tom Cook, M .S .P .T . from the REC tors during their affiliation time June 18, 1980. #2 attended the American Physical here . Students gain experience in Minassian, S . Rehabilitation Engineer- Therapy Association meeting held mAr- aspects of writing and implement- ing Service . Presented at Conference izona May 16th to 19th . They made on Vocational Implications of Spinal poster presentations as follows: ing a protocol designed to answer Cord Injury Rehabilitation sponsored "An Instrument for Clinical Analysis a particular research question in an by Temple University, June 4, 1980. cx8aiy' o!dTavo, (nmonnmd by area related to their assigned inves- Minassian, S ., Leiper, ,C ., Mayer, N . De- Carol Leiper); tigation . The individuel program for velopment of a Rehabilitation Engi- "Variations in Healthy Gait with each student is decided and agreed neering Service . Presented at ICRE, Changes in Ve! i ^ by R . Craik, T. Toronto, June 16-19, 1980. Cook, B . D'Orazio (presented by R. upon by the student and supervisor. Moskowitz, G .D . Rehabilitation Engi- Craik); By the completion of this affiliation, neering . at Temple Univer- "Facilitation of Movement by Afferent it is expected that the students will sity, Special Lecture Series, May 23, suimu!mion^ by R . Craik, A. DeLitto, T. have demonstrated an understand- 1980' Phiia,Po. Burke (presented by R . Craik) ; and ing of the following phases of the Myers, D ., Moskowitz, C .D . Myoelectric "BK Amputee Gait : Comparison using Knee Controller for AK Amputees. Walker and Parallel Bars" by T . Cook, research process : 1) "State of the Presented at ICRE, Toronto, June 16, B .A. Cozzens, V . Theerasakdi (presented Art" assessment, 2) Problem for- 1980. by T. Cook) . mulation and hypothesis statement, Taylor, D. An Instrument for Clinical 3) Methodology, 4) Data reduction Analysis of Gait . Presented at Ameri- can Physical Therapy Association and analysis, 5) Conclusions. Meeting, Arizona, June 18, 1980. Eight universities are currently af- Taylor, D . An Instrumented Gait Mat. filiating with the research center. Presented at ICRE, Toronto, 1980. The duration of the internship ranges from 4–8 weeks, depending on the school's requirements . Three Dissemination Activities students have completed their affil- 1. REC #2—Drexel University Collab- iations thus far this year. oration. Drexel University students, in collaboration and consultation with REC #2 and Moss Hoopital personnel, pre- Presentations and Publications sented several projects at the Drexel Cohen, L., Turner, K., Mayer, N . Func- University Senior Engineering Design tional Peroneal Nerve Stimulation and Symposium held May 14th and 15th, its Immediate Effects on Measures of 1980 . Projects of particular interest to Gait Performance . Presented at ICRE, the rehabilitation community were: Toronto, 1980. Control of Dyskinesia ; Philadelphia Cook, -[K8, Kenosian, H . The Use of Rowhouse Accessibility for the Physi- Force Visualization in Gait Analysis. cally Handicapped ; Home Transporta- Keynote address . Presented at the tion System for Quadriplegics ; and British Biological Engineering Society PODICAR : Independently Manipulated Meeting on Recent Advances in Podium/Mobility Device for Paraplegic Biomedical Engineering, London, Children. March 23—28 ' 1980. 2. REC #2 Participation in 1980 ICRE. Cook, T ., Cozzens, B ., Theerasakdi, V . 8K Dr . Gordon Moskowitz, Director of Re- Amputee Gait : Comparison Using habilitation Engineering Center #2, was Walker and Parallel Bars. Presented at co-chairman of a workshop on the re- APTA Meeting, Arizona, June 18, 1980. habilitation problems associated with Craik, R . Visual Guidance and Motor poverty and aging at the ICRE held June Performance . Presented at Research 18m through 19*^ . Eight other members Seminar Series, University of pvnn- of the REC #2 staff also participated in ov!venio ' March w` 1yoo. the Conference, including Charles Ph- Craik, R., Leiper, C . An Overview of Re- tham ' C.P .O, who served as an inmmo' 182 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

Rehabilitation Engineering Center University of Michigan Department of Mechanical Engineering WE . Lay Automotive Laboratory Ann Arbor, Michigan 48109

J . Raymond Pearson, M.Sc.M .E., Director

The overall concern of the Univer- ens Administration, consisted of neering (ICRE) in Toronto in June sity of Michigan Rehabilitation En- several components which needed 1980. The system is currently being gineering Center (UM REC) focuses to be installed in the engine com- readied for production. on the use of personal vehicles by partment and driver's compartment The brake power actuator will be persons with disabilities. Before the with mechanical, electrical and located on the oontrol handle unit person with a severe disability be- pneumatic connections between the and connected to the brake pedal comes a driver, it is necessary to components. The control-handle unit by a heavy Bowden cable and pul- determine his health utatuu ' pmrcmp- was located either on the door in ley attached to the floor . This ar- tue! capabilities, and the assess- front of the arm rest or on the en- rangement will eliminate the need ment of abilities in terms of range gine housing . The brake-actuating to find space in the engine com- of motion, strength, coordination, unit was located in the engine compartment to mount the actuator. It and control . Recently, important partment with the actuating cable also eliminates the need to pass the progress in the UM REC has been passing through the firewall to the brake operating cable through the achieved in the areas of the design brake pedal . The accelerator amua- firewall. The accelerator actuator will and development of vehicle adap- torsam mounted either on the en- be mounted above the pedal and tive devices and systems, and in the gine near the throttle linkage or connected by a direct linkage : This evaluation and design guidelines for above the pedal in the passenger system will thus be entirely in the wheelchair neytraint systems . Prog- compartment . Vacuum reservoirs passenger compartment, except for ress has also been noted in the and system monitors were located the vacuum supply connection and physiological and psychological where convenient. possibly the vacuum reservoir, factors affecting driver perform- Installation and interconnection of which requires only a single hose- ance, and in the area of vestibular these components was often diffi- connection through thefinewa!!. insufficiency in drivers with hearing cult and critical because of space impairments. limitations in the engine compart- Adaptive Vehicle Systemms—A group ment . It was not always possible to of meohaniuul engineering stu- align the brake actuator with the dents, under the direction of Profes- RECENT ACCOMPLISHMENTS pedal for best operation . Concern sor Mohamed Zarrugh and David H. has arisen about the availability of Harden, are working on the design Design and Development of proper installation facilities for this and construction of a prototype Vehicle Adaptive Devices system . (Reliability depends upon wheelchair that will use a General and Systems proper installation and lack of com- Motors X-body (2-door sedan) mod- Task Leaders: plexity.) Over 20 of the original sere ification in accordance with the Robert Di duvinall, vocontrol units have been installed "door-mounted chair^ concept . The David H. Harden by CCI in vehicles for drivers with concept for the driver's side is being severe disabilities . Most of the units developed at the UM REC (Fig . 1). Recent effort in the UM REC has were installed in vans because vans The lifting sequence proceeds as been divided between the tempo- were necessary for persons who follows. After the door on the rary solution of improving the safety could not transfer to the driving po- driver's side is opened, the chair is and convenience of driving a van sition in a standard passenger au- wheeled into position onto a bracket from a wheelchair, and the long-- tomobile. and is attached to the door . The range solution of providing a mini- Preliminary tests at the UM REC, wheels and suspension assembly of mally modified standard passenger plus the experience of drivers who the chair are retracted from below car for the driver with a disability. use this control, have led to the be- so that the chair envelope comes lief that this unit has oon1rol char- within the door opening and the Servo Controls—The servo brake acteristics superior to those of sim- door closes automatically to place and throttle oon(rol which was de- ilar units that have come to our the chair in the driving position . This veloped by Rehabilitation Institute, attention. operation necessitates strengthen- Inc ., of Detroit (RI) and Creative Design and prototype construc- ing the door hinges and modifying Controls, Inc., of Troy, Michigan, tion of the new servocontrol system the door to increase its range of (CCI) is being redesigned for ease has been completed and the unit motion and to allow attachment of of installation . The first model, was displayed at the International the lifting bracket . The chair is which was evaluated by the Vetere- Conference on Rehabilitation Engi- equipped with a powered footrest .

183 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

A similar approach for a passenger who uses a modified AMIGO- type device (Fig . 2) is being developed by the AMIGO Sales Corp, Inc., a subcontractor of the UM REC. In this prototype the occupant is lifted through the right door of an X-car . Entry into the car involves opening the door, swinging a bracket arm out to attach the chair, and raising the lower section of the wheels of the chair . The special arm bracket swings back into the car, and the door can then be closed. Wheelchair Restraint Systems—A motorized wheelchair tie-down system for use in vehicles by either a driver or a passenger in a wheelchair has been developed by Crea- tive Controls, Inc ., (CC!) of Troy, Michigan, a subcontractor of the UM REC. This system was displayed at the ICRE in Toronto . It provides for automatioanouremont of the wheelchair to the vehicle by operation of an electrical switch. The design provides a way of transmitting the seatbelt forces to the vehicle without loading the FIGURE 1. Concept drawing of prototype wheelchair for entry on driver's side of car. wheelchair with occupant-restraint forces during a crash . Sled impact tests at the Highway Safety Re- search Institute (HSRI) used a 50th percentile male crash dummy and demonstrated that this device provides effective restraint of the wheelchair and occupant . (K8oroef- feotive occupant protection is provided if an upper torso belt is used with this system .) The conventional wheelchair is modified to include two approximately triangular-shaped side plates (Fig . 3> . Thome plates are easily installed by removing the large wheels and clamping the plates to the tu- bular frame by two sets of U-bolts. The front and rear lower corners of these plates are provided with holes through which two steel retaining rods are inserted and held by means of retaining pins . These rods can easily be removed to allow folding of the wheelchair . Holes located in the upper part of these plates provide solid anchoring points for the lap belt at a point where it is properly positioned across the pelvis of the occupant. d with these plates and FIGURE~~Um~ 2. Equipp e Concept se- 184 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

the platform has wheelwells for lowering the rear of the wheelchair. With this system, the large wheels of the chair are lowered into the wheelwells as the powered linkage grabs the front retaining bar and moves the chair and rear retaining bar into the locked position . With this system also, the chair is completely supported by the retaining bars and in the final locked position the occupant is in a position similar to that provided by a standard vehicle seat. This driver-restraint platform must be securely welded in place after cutting out appropriate rectangular sections of the vehicle floor to accommodate the wheel- FIGURE 3. wells. Conventional wheelchair with triangular side plates developed by CCL An alternate wheelchair driver-restraint system has been designed to lower the rear of the chair without the need for wheelwells or a lowered floor in the van (Fig . 6) . A power actuator changes the position of the wheels on the chair ; the chair frame itself is lowered to the floor as the restraint mechanism is put into effect . (Other benefits of this system are that the entire system can be bolted to the van floor or moved to adjust the driver's position . It could also be moved from one vehicle to another .) This system is also based on the use of two added triangles of metal inside the chair frame to transmit the restraint forces through to the vehicle . The rear wheels are attached to the triangles on an axle that pivots to change the wheels' position . A prototype of this system FIGURE 4. was also displayed at the ICRE in cc! restraint system for passengers or drivers below the av- Toronto. erage male stature.

Evaluation and Design Guidelines cured in position by a locking plat- jected to any loads during opera- for Wheelchair Restraint Systems form. When the wheelchair is position of the vehicle. Lawrence W . Schneider, Ph . D. tioned over the platform, an For passengers and drivers below electrical switch will operate a mo- the average male stature, the sys- Wheelchair restraint systems torized actuator linkage which grabs tem can be used as shown in Figure should provide the occupant of a and lifts the front retaining bar and, 4. In this case the locking platform wheelchair with effective impact in the process, pulls and tilts the is simply bolted to the vehicle floor protection on survivable collisions wheelchair so that the rear retain- with a plate under the vehicle to comparable to the protection pro- ing bar sets securely into its attach- distribute the loads . For taller driv' vided by the existing restraint sys- ment position . In the locked posi- erS, the chair must be lowered for tems required on today's automo- tion, the chair and occupant are better driver visibility and access to biles for the rest of the population. completely supported by the trian- steering and hand controls . Lower- A good restraint system should gular side plates and bars : the ing is accomplished with a platform contain the occupant within the ve- wheels of the chair are not sub- (Fig. 5) inset into the vehicle floor : hicle, protect the occupant from 185 Bulletin of Prosthetics Research, ~R 10-34 (Vol. 17 No. 2) Fall 1980

wheelchair that held a dummy representing a 6-year-old child . The wheelchair was held by wheel rim pins, and the dummy was restrained by a padded belt . On impact the chair tipped forward, the dummy flexed forward with much head excursion, and the padded belt pressed on the soft obdominol re- gion . An adult dummy was then tested in a forward-facing wheelchair with a lap belt, and the chair was held down by a press-down bar on the left wheel . No restraint was provided to the chair itself. The press-down bar broke early in the impact. In the restraint system developed by CCI under a subcontract from the UM REC, vertical triangular plates connected by horizontol energy-absorbing bars were bolted to a wheelchair (Fig. 7). Powered clamps held the bars, apparently securely. The lap belt was mounted to the plates . A 50th percentile male dummy faced forward during the tests. During the test impact, the wheelchair held securely but the front bar popped out of the grip. The dummy flexed forward with extensive head excursion (Fi g . 8). When a shoulder belt was added to this system (Fig . 9), the wheelchair remained in position and good restraint was provided for the occupant. Little upper torso and head FIGURE 5. excursion resulted. . Note wheel-well CCI restraint system for drivers of average male stature or above Aeroquip Corp . straps were at- inset into vehicle floor. tached to a forward-facing wheelchair occupied by a 50th percentile second impacts with the vehicle in- both the wheelchair and the occu- male dummy (Fig . 10). The rear terior, provide restraint as soon as pant must be automatic, or nearly strap was attached to the crossbars possible to allow maximum ride- so, for the person with a severe dis- (Fig. 11) and the two front straps to down time with vehicle crash, and ability to be independent. the frame members in front. When should apply restraining forces to Most wheelchair tie-down and re- the lap belt was mounted to the CCI the skeletal regions rather than to straint systems would not provide plates on the chair and a Y-yoke soft abdominal areas. very effective protection in moder- shoulder harness secured above and The 3-point belt system, properly ate or severe crashes, and many are behind the dummy's head (simulat- worn, provides effective restraint for probably inadequate even for emer- ing attachment to the vehicle) was ablebodied persons and for persons gency vehicle maneuvering . Sled anchored to the plates at the lower who can transfer from wheelchair impact tests were carried out at the end, this system provided good re- to vehicle seat . For the person who Highway Safety Research Institute straint for both the dummy and the remains in the wheelchair, the fol- (HSRI) in conjunction with the UM wheelchair . But when the Y-yoke lowing conditions also apply : (i) The REC. Most of the tie-down and re- harness was replaced by shoulder wheelchair must be securely tied straint systems currently being used belts wrapped around the wheel- down so that the chair does not col- performed poorly on these tests, but chair handles (Fig . 11) and an- lapse or break apart, (ii) the occu- improved performance is possible. chored to the CCI plates, the wheel- pant must be provided with an ef- The tests were 20-mph, 16-G im- chair crossbars broke and the chair fective upp e r and lower torso pacts. flew loose and smashed into the restraint, and (iii) the restraints of One test used a forward-facing front of the sled . When the two

186 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

Aeroquip straps were attached to the rear verdoml tubing of the wheelchair just above the CC| triangles instead of attaching a single strap to the crossbars, good restraint of the wheelchair was provided—however, the wheelchair handles bent forward during impact (Fig . 12) . Some upper torso restraint was provided but this was not adequate. In side-facing wheelchairs, a dummy representing a 6-year-old child and a 5th percentile female dummy were restrained with padded belts. The wheelchairs were restrained by wheel rim pins (Fig . 13, left) or belts mounted to the side wall (Fig . 13, center) . The chair twisted and tipped sideways, and the dummies collapsed onto the floor . The dummies also flailed sideways in the chair (Fig . 13, right and Fig . 14, right), and the head im- pacted with the side we!l of the vehicle.

FIGURE 6. CCI Low'r-N-Lock wheelchair restraint system for drivers.

FIGURE 7. FIGURE 8. Restraint system developed by Creative Controls, Inc . (CCI) Dummy flexed forward with extensive head excursion after with a 50th percentile male dummy in the wheelchair . impact in CCI system with lap belt restraint only . 187

Investigation of Physiological and Psychological Factors Affecting Driver Performance Michael Sivak, Ph . D. A battery of 14 paper-and-pencil tests to measure perceptual/cogni- tive abilities was administered to 41 persons . When necessary, the standard administration procedures for the various tests were modified to accommodate thechanged com- prehension abilities of the persons with brain damage. The subjects included 23 persons with brain damage, 8 with spinal cord injury, and 10' ablebodied controls . Off-road and open-road driving courses were developed and the latter was com- FIGURE 9. pleted by 37 of the 41 research sub- OCI System with shoulder belt provided good restraint. jects . The results of this study indicate that some of the pmper-and- penoil tests are good predictors of driving performance . A complete report of this study is available through the University of Michigan Rehabilitation Engineering Center, 208 W. E. Lay Automotive Labor - tory, Ann Arbor MI 48109.

Vestibular Insufficiency in Drivers with Hearing Impairments Ti Dean Clack, Phi D ., Wanda 0i Milburn, Ph . D. In the investigation to examine the relationship between otolithic insufficiency and certain extraoou- !sr muscle functions as revealed by eyeball oountmrno!La behavioral ' terimage approach for determinini counterroll is being compared wi a method that uses a photographic procedunai A pilot study of 4 subjects showed considerable agree- ment between the amount of counterroll observed using each method. In order to document the extent to which otolithic insufficiencies may impair a driver's ability to see under some road conditions, a road- side reading task is being developed.

FIGURE 10. Foward-facing wheelchair with dummy positioned for sled tests at FISRI .Aeroquip tie-down straps are attached to the front side posts. 188 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

FIGURE 11. Rear Aeroquip strap comes around the crossbars of the wheel-chair.

FIGURE 12. Wheelchair restrained by 4 Aeroquin straps attached to front and rear vertical tubing and dummy restrained by lap belt and shoulder belts attached to wheelchair handles. The hand!etubingbontfonwevdduring impact but good restraint was provided for the wheelchair by 4-point tie-down.

FIGURE 13. Left . This dummy representing a 6-year-old child is restrained to chair with a padded belt . Wheelchair is restrained with ,°hovl rim pins . Center . Same dummy with vvhmo!ohai, restrained by 2 belts anchored to side wall . Right . Child dummy in side-facing wheelchair after impact.

189 BuWetinof Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

FIGURE 14. Crash tests of 5th percentile female dummy in wheelchair. Left : Action shot . Right : View after impact.

Cairo Rehabilitation Engineering Center capped ; design and manufacturing of utensils and equipment to im- Arab Republic of Egypt, Ministry of Social Affairs prove their activities of daily living. Mugamaa Building, Tahrir Square, Cairo, Egypt The Cairo REC is very much concerned with introducing the concept Dr. Salah El-Din El-Hommossani, Director and Principal Investigator a of rehabilitation engineering in different organizations concerned with the rehabilitation of the disabled in Project scope and objectives Its main objective is to apply and Egyptian society . Also, to get in The Cairo Rehabilitation Engi- deliver modern technology to en- touch with various induotriol organizations to raise their interest and neering Center is a research project hance the lives of the disabled in which was established as a result of the home, oommunity, and vuoa- encourage their help in the program cooperation between the Ministry tionul setting . Direct and close co- of rehabilitation engineering as a human necessity. of Social Affairs and the Rehabili- operation between m*dical personnel, engineers, industry, and all The center works in close coop- tation Services Administration of the eration with the faculty of Biomedi- United States in 1974. professionals involved in the rehabilitation of the disabled population cal Engineering in Cairo University. is a guiding principle. "The Executive Committee of Dr . Horn- Organization mossani's project included the follow- The core area of activities of the ing at the conclusion of the Dec. 1978 center includes the following: The main activities of Cairo REC to Dec . 1979 period covered by this re- 1. Designs and development of are located in the Day Hospital Cen- port: standards for a barrier-free environ- ter. This is a comprehensive reha- Dr. Sa!ahEl-Din B-Hommnosani; ment to be accessible to the handi- bilitation center with 52 beds, out- Dr . Hussien Abdel Fattah, Prof . Or- thopedic Surgeon, Cairo University; oapped.foouonod on apinal cord inpatient deportment, prosthetic/ Mr . miAuue!Ghwaar(Co-pvinvipu! In- jury cases—taking into consideration orthotic workshop, and a sheltered vestigator) Counseling and Executive that such an achievement will solve workshop with vooadonel training Director; most of the barriers for other hand- facilities. Dr . x0nhamad4bdel RaoakF"vda .Direc- tor o,Agouza Rehabilitation Center; icapped persons. Although it is a separate activity, Dr . Mohamed Abda Salam EI-8vnma, Co- 2. The care of spinal cord discon- most of the Cairo REC team is in- principal Investigator tinuity population in Egypt after the volved heavily in it . This environ- Mr . Mohamed Mahrous—Left for the acute-care period, until they are fully ment provides a perfect setup for United States to obtain Ph .D. in Re- habilitation integrated in society. the research, development, and N .B.—General Hassan Hussni, M .D., died 3. The study and development of evaluation programs . The SCI reha- Aug. 1979 . mobility systems for the hendi- bilitation area is in a separate 20' 190 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

bed ward in this center, modified to patients in the spinal cord service ronment was set up to be barrier- be barrier-free . The electronic work- area. free. shop is located in the center. The second group includes a few There are still 12 cases waiting The Cairo REC is closely associ- cases of complete traumatic lesions for their rehabilitation program to ated with WAFA WA AMAL Society of the spinal cord but mostly partial be completed. which is the main core area of re- lesions . Most of the partial lesions search on architectural barriers for are cases in wheelchairs . These the handicapped . Also, the team of need only one or a few particular From the second group we have Cairo REC is responsible (with staff rehabilitation services so that they 50 cases (42 males and 8 females) in WAFA WA AK8AL Society) for can be integrated in society—a mo- of ages between 12 and 47 years; solving patient problems in their ac- bility aid, elimination of barriers in 14 of them are quadriplegics with tivities of daily living and providing their homes, transfer to another job partial lesions at C6, C7, and C8, work environment in this rehabili- in their places of work, etc. with some recovery in hand func- tation complex . The team also pro- These cases are either admitted tion, and 36 are paraplegics . These vides services for the prosthetic fora short time in opinal cord injury cases are served in a variety of workshop in VVAFAVVAAyNAL . and service beds, or they are not admit- items according to their needs, and professional help. ted at all and the services are pro- are fully integrated into society. The vided to them directly in their homes services provided to these cases in- or places or work. clude moblity aids, minor alteration Achievements during 1978 -1979 The third group are the cases of in their homes, assistance in chang- spinal cord discontinuity living in 1 . Spimml cord patient service ing their work places, provision of VVAFAVVA A yWAL Society. area—The main objective of this seating pads for wheelchairs, teach- service area is to integrate spinal From the first group we have now ing urinary hygiene, counselling, 22 cases (19 males and 3 females) cord discontinuity patients fully into and psychological adjustment. who have been integrated fully into society and prepare them to earn From the third group, in WAFA their living independently . The main society and who are still followed WA AMAL, we have 70 paraplegics steps of integration include physical up; some of them have completed living in society, and all of them restoration, treatment of urinary in- 2yuam. Their ages varied between now are provided with jobs. fections and bed moreo, training on 19 and 40 years. There are also 77 cases served as ADL on wheelchairs, social counsel- The jobs provided are the follow- in-patients or out-patients in the ing, visiting homes to study ways to ing: spinal cord injury service area but eliminate barriers, and planning for Knitting and sewing machine oper- they are not affected with spinal jobs to make individuals independ- ators : 5 cases are supplied and cord injury . These are severely ent for their living. trained to work on these machines, handicapped cases with neurologi- Most of the above steps are and they are linked with the produc- cal or orthopedic conditions, re- standard prootioos, but the chal- tive family project under care of ferred to the project for services lenge in mpinel cord discontinuity n~'°"nnel from their district rehm- available in the Rehabilitation Engi- cases is to integrate them so that i/~/ h cn offices, who deliver mate- neering Program. they can be independent . This re- them and collect their work From our experience in the past quires provision of suitable jobs. . `, sr'ling in the community, and 3–4 years with spinal injury cases This is not easy, because some of them directly. we have identified some points them cannot return to their original Kiosk : 7 cases are provided with which should be mentioned . The jobs due to the disability and also stands or kiosks near their homes, opinal injury cases in Egypt are their living and work environments to sell cigarettes and haberdashery. mainly among the young male pop- need to be modified to eliminate Small grocery shops : 4 cases have ulation (20–40 years) and the per- barriers. We have divided our cases been helped to establish this kind of centage in the Egyptian community into three —rips.~ small business because they had is less than the international figure The first :o[ includes cases with previous experience. Some share (15 per million) . The main cause is a complete t3umado apinal cord le- the business with their relatives. falls from higher places, second is sion who lost their ability to return Electronic repairs : One case had a motorcar ucnidente, and third is to their previous jobs and .need re- training course in repairing radio knife wounds (rarely gunshots), plus habilitation care such as treatment and television (he was electrician war victims . The incidence of trau- of bed sores, training in AM. and before injury) and he is now work- matic cases is more than cases use of mobility aids plus training on ing in a shop. originating from non-traumatic con- new jobs—or providing them with Commercial projects : 5 cases were ditions. new vocations in which they will be provided with commercial projects The period of time needed, after able to earn their living independ- according to their previous ability. the acute-care period, until the case ently. All these cases are provided with is fully integrated into society is Their new work environment and mobility aids : 14 of these cases fairly long in the cases complicated their homes had to be barrier free. needed alteration to their homes to by urinary infections or bedsores, All these cases are admitted as in- eliminate barriers . Their work envi- or among individuals with a poor 191 Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

educational background or low so- brake were put on the right side of HI—Barrier-Free Environment De- cial standards. the steering whool and brought up sign and Modification Studies— These findings indicate the neces- close. The leverage action is de- Studies on barrier-free environment sity of establishing acute-care cen- signed to need less force for ma- had been going on, due to the ex- ters for epinol cord injury cases to neuvering, so that the body remains tensive amount of literature on that eliminate urinary and skin troubles, balanced . Improving the control of subject . Most of the Swedish, as it will save time and services for clutch and brake can make the car American, and Canadian literature treating these cases . Later, this will controllable when stopped on an was available to the committee . It save a lot of expense, which imea- upward incline. must be noted that we found that peuia!!y important when the re- The design was tested and ap- the "Resource Guide to Literature sources of the community are lim- proved by Nasr Company and it is on Barrier-Free Environment 1977," ited. Also important is the fact that now made locally with a reasonable from the American architectural and delay in integrating these cases into cost of LE 150 . The design can be transportation barriers compliance society may lead to harmful pay- fitted to model Nasr 128' Nasr 131 board, was very helpful . Most of the cho!ogioal impact on the individuals and Nasr 132 cars produced in standards and specifications for themselves. Egypt; also for Renault 12 cars. making homes barrier-free are The REC team, together with known, but the challenge is to effect VVAFAWA AK8AL Sooiety, got in these modifications in the buildings N Driving-for-the-Handicapped Pro- touch with Naser Bank to sell these in a community in such a way as to gram—Our previous published re- cars to the handicapped on 5-year be usable in practice by the handi- ports have described an adaptive easy terms . Also, the Ministry of the capped, and to suit their life-style device for use on standard-trans- Treasury agreed to sell modified according to their liking, and also mission (hand-shift) cars. cars to the handicapped tax-free (the suited to the outside environment— The device was designed to be import tax on cars is 100 percent). and we must not forget the amount used by opinal cord injury cases in A plan has been worked out for of money available forth* purpone, '1otal hand-oontnol driving^ It con- an official committee with one especially in communities with !im- sisted of one handle with accelera- member from the REC and a repre- itodr*eouroea. tor (motorbike type) which moves sentative from traffic control, and So the committee urged that var- on an axle hooked on the steering an engineer, to examine all handi- ious designs be available with dif- wheel . When the handle is pressed capped persons who apply for mod- ferent styles and price ranges. downwards, it depresses the clutch ified cars weekly, with meetings in Although most of the modifica- pedal by lever action, and if it is WAFA WA AMAL Society and, alter- tions and designs were for wheel- pushed more, both brake and clutch natively, in the central office of chair uoem, it is felt that all other pedal are depressed . About 40 cars Medical Examination in the Ministry handicapped should be included in have been supplied with this de- of Health, to prescribe the suitable one program . Also, it is felt that vice. The result of evaluation of this device. much more effort is needed to en- device showed that it needs consid- That committee started its work courage the Ministry of Housing to erable power in the left upper limb in mid-1978. Over 300 modified cars adopt these modifications in all and good balance of the body dur- had been authorized to the handi- public places in Egypt in hot*!a, ing maneuvering. capped by the end of 1979 . The pro- theatres, and airports. Also, it was noticed that the car gram included modification for to- The Ministry of Social Affairs is had to be slowed down during shift- tal-hand-control driving for the still pursuing the proposal that in ing because the left hand is press- paraplegics, and had been extended all governmental apartments the ing the clutch and the right hand is to include various modifications for first floor should be kept to the moving the gear lever, and this is a different disabilities . We now have handicapped, and also a proposal moment where the steering wheel devices for lower-limb amputee, to the parliament requiring a certain is left free . It is felt that this is a right and left . For the right lower- percentage for the handicapped in d,avvbaok, although most of the limb amputee, the accelerator and government-funded housing proj- clients can drive like this. brake are operated by hand. For the ects . Although mevoral modifica- The other discovery was that it left lower-limb amputee, the clutch tions had been done in various was difficult to control the car when pedal is controlled by hand. homes in Cairo and rural areas, we starting up from a stendsd!l on an Present legislation recognises the foel that if some form of legislation upward incline. right for all amputees to have mod- deals with that subject in Egypt, re- For these reasons another design ified cars, although in fact not all of search will be speeded up tremen- was worked out . The accelerator them require that. dously in this area as happened with was a lever on the left-hand side, We have also modification for left our driving-for-the-handicapped close enough to the steering wheel hemiplegics, but not for right hem- program. However, the information so that it can be grasped and con- ip!egiou' and we od!l have no mod- and experience gained by these re- trolled by the fingers while the ification for bilateral arm amputees . search studies is not going to be thumb is available to control the wasted : it is going to be put into wheel . The handle of clutch and practice in the new flats outside 192 NATIONAL INST. of HANDICAPPED RESEARCH PROGRESS REPORTS

WAFA WA AMAL Society for the Most of these are for polio patients. expected that a full report will be handicapped. So it was decided to approach this submitted at the end of 1980. problem in two research programs. This cooperation between Cairo Co-operation in activity of WAFA The first is to manufacture a mod- REC and the faculty of Medicine and WA AMAL Complex--The main ac- ular system for above-knee or- the Institute of Physical Therapy was tivity in the last period was to su- thoses with knee joints from dural- a fair approach to introduce a re- pervise the installation of the equip- uminum, with the cooperation of habilitation engineering concept to ment and modification of the industry . Pattern is identified and the Egyptian medical professionals. building in WAFA WA AMAL pros- production will start in 1980 . The thetic orthotic workshops . A limited second is to introduce polypropyl- Gait Analysis Research area of 5000 square meters from ene orthoses for polio patients. The The three-dimension gait dy- the original plan was chosen forth* advantages of polypropylene in its namic equation of motions, using location of the workshop, and 180 light weight and strength properties periodic optimum control, is still tons of equipment was distributed was proved in many centers all over waiting for use in computer diag- in the area after it had been divided the world. nosis technique . The computer is in 3 divisions : o1inioal area, fitting A study was made of the various presently installed in the biom*di- area, and production area . The task items of equipment used for pro- oal engineering Dept . in the Faculty was finished and production will duction of these braoou, and a ma- of Engineering, Cairo University . Dr. start in February 1880. chine was chosen, together with 500 Hashish, Assistant Professor of sheets of polypropylene with the Prosthetic & orthotic activity Biomedical Engineering, is follow- correct number (as advised by Moss ing this up. The prosthetic and orthotic work- R .E . Center) . The machine is sup- Aluminum walking platform has shop at the Day Hospital Center, plied with infrared heater on top been built in the R .E workshop in which is the main research facility and three frames up to 800 x 600 Cairo Hospitals' Day Center . Four for Cairo REC team, produced the mm, and automatic control . The electrodes are fixed to the patient's following items in 1978. sheet is raised automatically to the feet to make four points of contact P .T.B. prostheses : 168 heater and when it is heated it to detect the time between heml AK prostheses : 82 comes down in the plaster model strike and 5th metalarsal ; 1st mmta- Leather above and below knee con- and vacuum is applied . The ma- {omml and big toe . Signals from the ventional prostheses : 822 chine can blow air to adjust the contacts are displayed by four Above and below knee orthoses: melted sheet and prevent webbing ohanno! oscilloscope (Disa 1500) . Dr. 2200 of polypropylene around the mold. James B . Reswick inspected the Upper-limb prostheses : 79 The machine was ordered and pro- work and he suggested installation Hand-driven wheelchairs : 220 duction of switches from Ranch Los Ami- Tricycles : 240 gos. The system is completed and Motorized tricycles : 5 Evaluation Program: ready for use. Experiments with the air-pressure It was noticed that demands of transducer are oing on, to make the patients for orthoses has in- g Education Program seating cushions for paraplegics. creased and that is due to the new The team of Cairo REC feels that The main evaluation activity was systems of the services for the gov- education is the most important in the area of biofeedback tech- ernorates of Egypt where a team channel by which rehabilitation en- nique, taking the Limb Load W1oni- visits and takes measurements of gineering ideas and concepts can toru as an example . It was discov- the patients and delivers the or- be propagated among the Egyptian ered that biofeedback procedure and thoses so that for 1978about 30O0 noedioal and rehabilitation profes- technique was fairly new and not in braces were supplied. sionals and also the community at o!inioal use in the Egyptian Medical This stimulates a study of the large. Institutes . So, with cooperation of needs for prosthesis and orthoses There avemany joint activities be- the Physical Therapy Institute and all over the country, and especially tween membomofthateamandthe the Faculty of Medicine of Cairo to plan policy for production which faculties of medicine of Cairo and University, research was conducted meets the needs of the population Ein-Shams Universities, in the forms into biofeedback theory and philos- as a whole. This was felt am'neoeu- of lectures and also research pro- ophy, techniques, and equipment, oity because a plan for WAFA WA grams which offer use of the REC with clinical demonstration and AMAL prosthetictorthotic workshop workshop facilities and equipment evaluation of the Limb Load Moni- is also needed. for measuring vital functions . An tor. The work is going on, and it is Data of production of prostheses example of these research pro- and orthoses collected from all grams is the study of problems of u workshops over the country showed S*e : Wannstedt GundC,oikR . : Clinical uko!otal overgrowth after surgical that the total production of lower Evaluation of a Sensory Feedback De- amputation in children, done with vice and upper limb prostheses in : the Limb Load Monitor (Moss Re- the Department of Orthopaedics. Egypt habilitation Hoop Phila . Pennsylvania). is around 4000 per year . For or- Bull Prosth Roo8PR 10-29, Spring 1978, Also, the team offered EMG facili- thoses it is around 6660 per year. pp. 8-49. ties for a research program study- 193 Bulletin of Prosthetics Research, ~~~34 (Vol . 17 No. 2) Fall 1980

ing the intercostal muscles in chronic obstructive pulmonary dis- ea000 ' with the Department of Chest Diseases in Ein-Shams University. That study is completed. Also, the REC team is actively engaged in teaching for the rehabilitation counseling program . And the Cairo REC team is taking responsibility for establishing an audio-visual library on rehabilitation . A complete color video cassette recorder, studio color camera and monitor, etc ., have been bought and materials are being collected for display and teaching use by rehabilitation and medical professionals. We also will produce reports about activities in video cassette for the next years . Also Cairo REC is involved with the new Department of Systems and Biomedical Enginamr- ing.vvith the Faculty of Engineering, Cairo University, started Oct . 1860. By the next academic year, in Oct. 1980, graduate programs will be started with the following subjects: 1. Control and system engineering. 2. Biomedical modeling and simu- lation. 3. Biomedical engineering. 4. Honpi1al systems design and organization. 5. Management systems and health care delivery. 6. Elective: a. Rehabilitation engineering; b. Nuclear and radiological equipment; c. Medical electronics: d. Artificial organs; e. Process control and instrumentation ; and f. Nonlinear control system. The candidates must have a research project as well . So we ex- pect to have graduate engineers specialized in Rehabilitative Engi' neering, after mid-1981 .