US20050113652A1 - Remote psychological evaluation - Google Patents

Abstract

Instrumented orthoses with more sophisticated structures provide for coordinated support and rehabilitation of complex joints and multiple injured joints. Improved instrumented orthoses can include hinges that can rotate in multiple different planes. Particularly preferred embodiments include a shoulder brace with a hand hold and a lower extremities brace. Preferably, a control unit monitors the output of transducers used to instrument the brace. A patient can be prompted by the control unit for the performance of a variety of different monitored exercises.

Description

• CROSS REFERNECE TO RELATED APPLICATIONS
• This application is a continuation of copending U.S. patent application Ser. No. 09/339,071 to Stark et al., entitled “Rehabilitative Orthoses,” incorporated herein by reference.
BACKGROUND OF THE INVENTION
• The invention relates to orthoses useful for the rehabilitation of patients with injured joints, weakened joints, and/or neurological deficits degrading motor control or operation of joints. More particularly, the invention relates to instrumented orthoses for the performance of monitored rehabilitative exercises.
• Both muscles and bones should be exercised to maintain strength. Also, bone fractures that are exposed to permissible weight bearing stress often heal more predictably and more rapidly than fractures that are not stressed at all. Improved healing based on application of appropriate stress is also believed to be true for connective tissue, such as ligaments and cartilage.
• In the case of neurological injury or degradation, the nerve impulse pathways that control skeletal motor functions and joints are interrupted due to loss of brain cells or nerve conducting structures. Such neurological injuries can result from cerebrovascular accidents such as ischemic or hemorrhagic strokes or certain types of head trauma. Recovery mechanisms involve creation of new neurological pathways by retraining the motor functions with different surviving brain cells as receptors. This requires physical therapy and joint exercise very similar to exercise that is advantageous for rehabilitation of joints following orthopedic injury. Additionally, joint disuse following such neurological injury similarly requires orthopedic rehabilitation and stress to effect useful recovery, given the secondary orthopedic damage resulting from the disuse.
• Suitable stress can be applied to the tissue by the performance of selected exercises. For example, isometric exercises generally involves the exertion of force against a relatively immovable object. To perform isometric exercises, a restraining device can be used that has a substantially unchanging position for the duration of a particular exercise routine. Isotonic exercises involve exertion against the same weight or resistance through a range of motion. Isokinetic exercise is designed to mimic exertions that take place on a playing field or the like. When performing isokinetic exercises in a simulated environment, a machine is used to provide resistance in direct proportion to the exertion of the exerciser.
• Isometric exercises are particularly usefull with painful injuries to lower the risk of further injury. If performed in a controlled manner, isometric exercises can be performed earlier in the recuperation period to speed recovery. As the patient's recovery progresses, isotonic exercises or other exercises can be used to reestablish a desired range of motion about a joint. With continuing recovery, eventually the patient is able to perform a full range of exercises.
• A difficulty with the application of stress to an injured joint is that the application of excessive stress can further injure the joint rather than assist with the healing. Thus, the exercises need to be carefully planned to provide appropriate amounts of stress. Also, the performance of the exercises should be monitored closely by a physician, physical therapist or other appropriate health care professional to optimize the treatment and to reduce the risk of injury. The need to carefully plan and closely monitor the exercises provides a cost and motivation barrier to accessing desirable amounts of exercise.
SUMMARY OF THE INVENTION
• In a first aspect, the invention pertains to an instrumented orthosis comprising:
• • a support that fits around the joint of a patient, the support comprising a hinge that can rotate in different planes;
  • a position sensor operably connected to the hinge such that motion can be measured with respect to different rotational motions about the joint; and
  • a control unit operably connected to the position sensor to receive signals related to the position of the hinge.
• In another aspect, the invention pertains to method of rehabilitating a joint that has a range of motion in a plurality of planes. The method involves exercising with an orthosis having a hinge that can rotate in different planes. The hinge preferably includes a position sensor that can provide measurement of the orientation of the hinge in the different planes. The orthosis includes a control unit connected to one or more position sensors.
• In a further aspect, the invention pertains to an orthosis comprising:
• • a support that fits around a plurality of joints of a patient, the support comprising a plurality of hinges such that motions about separate hinges correspond to motions about different joints;
  • position sensors operably connected with the hinges such that motion can be measured about different joints; and
  • a control unit operably connected to the position sensors to receive signals related to the position of the hinges.
• Moreover, the invention pertains to a method of upper body rehabilitation comprising exercising two or more adjacent joints using an ambulatory orthosis supporting the two or more adjacent joints. The orthosis preferably is connected to a control unit that provides a target exercise routine and immediate feedback on patient performance relative to the target exercise routine with respect to motion about either of the adjacent joints.
• In additional aspects, the invention pertains to a leg orthosis including:
• • an ambulatory support structure including:
  • a waist support;
    • an upper leg support;
    • a lower leg support;
  • a hinge connecting the waist support with the upper leg support;
  • a hinge connecting the upper leg support and the lower leg support;
  • sensors operably connected to the support structure to measure forces applied to the support structure; and
  • a control unit connected to the sensors to receive measurements related to the applied forces.
• In another aspect, the invention pertains to a method of rehabilitating a stroke victim including performing a set of exercises using an ambulatory orthosis supporting the hip and knee. The orthosis preferably is connected to a control unit that provides a target exercise routine directing the application of forces by the patient at the hip and knee and provides immediate feedback on patient performance relative to the target routine.
• In a further aspect, the invention pertains to a shoulder orthosis including:
• • an ambulatory shoulder support;
  • a hand hold extending from the shoulder support;
  • a transducer operably connected to the hand hold such that forces applied to the hand hold result in an altered signal from the transducer; and
  • a control unit connected to the transducer to receive measurements of forces applied to the hand hold.
• The ambulatory shoulder support preferably includes a trunk support and an under arm support directly or indirectly connected to the trunk support by a hinge, preferably a multi-dimensional hinge.
• In addition, the invention pertains to a method of evaluating a patient's mental condition comprising:
• • collecting answers to a set of questions regarding the patient's mental condition using a remote controller programmed to pose the questions and receive the answers; and
  • evaluation of the answers by a health care professional.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a schematic perspective view of an orthosis for supporting two joints.
• FIG. 2 is a schematic perspective view of an orthosis with a hinge capable of rotating in multiple planes.
• FIG. 3 is a schematic perspective view of an embodiment of a support portion.
• FIG. 4 is a schematic perspective view of an alternative embodiment of a support portion.
• FIG. 5 is a sectional top view of a hinge with a mechanical locking feature and a position sensor, where the section is taken through the central axis of the hinge.
• FIG. 6 is a side view of a portion of the hinge ofFIG. 5 with another portion removed.
• FIG. 7 is a top view of an electromechanical hinge, where a portion of the casing and other structures are removed to expose internal structure.
• FIG. 8 is a sectional, side view of the electromechanical hinge ofFIG. 7 taken along line8-8.
• FIG. 9 is an exploded, perspective view of an embodiment of a mechanical hinge with an easy to use locking mechanism.
• FIG. 10 is a sectional front view of a manual resistance unit that can be used with the mechanical hinge ofFIG. 9.
• FIG. 11 is a side view of an orthosis with an articulating hinge connecting two support portions.
• FIG. 12 is a side view of a mechanical, biaxial hinge.
• FIG. 13 is a fragmentary, perspective view of one embodiment of a hinge that provides for motion in two planes.
• FIG. 14 is an exploded, perspective view of the principle components of the hinge ofFIG. 13.
• FIG. 15 is a fragmentary, perspective view of an alternative embodiment of a hinge that provides for rotation in two planes.
• FIG. 16 is a fragmentary, perspective view of an orthosis with a squeeze ball for the patient's hand.
• FIG. 17 is a fragmentary, perspective view of an orthosis with a squeeze ball ofFIG. 16 and a wrist hinge.
• FIG. 18 is a fragmentary, perspective view of an orthosis with a hand grip.
• FIG. 19 is a front view of a shoulder orthosis.
• FIG. 20 is a perspective, front view of a lower extremity orthosis.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
• Sophisticated instrumented orthoses/braces provide for more complex and coordinated rehabilitation exercises than previously possible. In particular, certain embodiments are suitable for the rehabilitation of complex joints that enable motion in multiple, different planes. These complex joints can be rehabilitated much more efficiently and appropriately using the more sophisticated orthoses described herein. Furthermore, other embodiments of the improved orthoses are particularly suitable for the rehabilitation of stroke victims. These stroke braces provide suitable rehabilitation for patients that have lost motor function on one side or both sides of their body. Thus, the rehabilitation can involve muscle building as well as neuro-reflex retraining. Using these sophisticated orthoses, many serious injuries/illnesses can be treated more effectively than was possible previously and, potentially, at a lower cost.
• Certain embodiments of the improved orthoses are suitable for the rehabilitation of joints that move in multiple planes of motion. Joints that move in multiple planes of motion include, for example, shoulder, spine, hip, wrist and ankle/foot. These orthoses include a support structure that fits around the joint and supports the body portions connecting at the joint. The support structure includes one or more hinges that provide for motion of the joint in multiple planes of motion. Position sensors preferably provide for measurements of the position of the hinge in the multiple planes of motion. The hinge or hinges preferably provide for the measurement of the motion about two or more planes of motion. The orthoses can include additional types of transducers, such as strain gauges. Preferred embodiments include instrumented shoulder braces that provide for the multiple planes of motion of the shoulder. Preferred shoulder braces can further include instrumented supports for the arm, elbow and/or hand.
• Certain embodiments of the improved orthoses are particularly suitable for use as a stroke brace. Stroke victims can lose a significant portion of their motor control on one or both sides of their body. These victims need a particularly high level of support and can benefit tremendously from appropriate type of rehabilitative exercises. Because stroke victims generally have injuries that involve multiple joints, a stroke brace includes a support structure that provides support for multiple joints. Preferred stroke orthoses include an upper extremity brace along with a long leg brace, although other embodiments can be used. In preferred embodiments, the support structures include hinges providing for motion of multiple joints.
• The hinges preferably include position sensors for measuring the motion about the hinge. The orthoses can include additional types of transducers, such as strain gauges. The orthosis can provide for multiple planes motion about one or more of the joints. The instrumentation of the orthosis generally involves a control unit that is operably connected to transducers on the orthosis. The control unit can be used to provide feedback and instructions to the patient to assist with the retraining of neurological pathways. Instrumentation of the orthosis reduces the need for professional intervention.
• Hand injuries may not be adequately treated by standard types of orthoses with hinges. Furthermore, hand muscles can atrophy due to inactivity following an arm injury. An improved hand orthosis includes an instrumented squeeze device, such as an air-bulb or a foam grip. Generally, the instrumented squeeze ball is supported by a support that extends, at least, to the patient's wrist. In certain embodiments, the instrumentation measures the total force exerted by the hand onto the squeeze ball. In other embodiment, the instrumentation provides for measurements of forces applied by individual fingers. The capability to measure the force exerted by individual fingers is particularly suitable for a stroke brace where redevelopment of neuromuscular control of the movement of individual fingers is a significant consideration.
• As noted above, preferred embodiments of the improved orthoses include a control unit operably connected to transducers placed on the orthosis for position, strain or other measurements. The control unit preferably includes a microprocessor to assist with the monitoring of the rehabilitative exercises. Information regarding the compliance and performance of the patient can be downloaded from the control unit for evaluation by a health care professional. Microprocessor based control units can provide instruction to and prompting of the patient for the performance of the selected exercises. The selection of suitable exercises preferably is performed by a health care professional following an examination of the condition of the patient. The control unit is programmed accordingly.
• 1. Orthosis Structure
• Previous instrumented orthoses are designed for placement around a single joint. Support portions support the respective body portions that meet at the joint. A selectively flexible connection/hinge connects the support portions at or near the joint such that rotation of the hinge provides for motion around the joint. Hinges used in these orthoses provide for rotation in a single plane. Transducers can provide for measurements of strain within the support and/or the position of the hinge. A microprocessor based control unit provides for monitoring of the measurements of the transducers. To the extent that previous instrumented orthoses have extended to multiple joints such as a knee brace extending to the foot, the measurements at the second joint have not involved rotation of the second joint. In other words, a force detector at the foot measures the force applied against the leg as a whole and not the force due to torque at the ankle. Further description of previous instrumented orthoses is found in U.S. Pat. No. 5,484,389 to Stark et al, entitled “Instrumented Orthopedic Restraining Device and Method of Use,” incorporated herein by reference.
• Various features of instrumented rehabilitation orthoses have been refined generally to provide for improved performance of the orthosis. Many of these features can be adapted for use in the improved orthoses described herein. These features are described in detail in copending and commonly assigned U.S. Provisional Application Ser. No. 60/098,779 to Stark et al., entitled “ORTHOSES FOR JOINT REHABILITATION,” incorporated herein by reference, hereinafter “application 60/098,779”. Certain of these features are described with particularity below, as appropriate. While application 60/098,779 is incorporated herein in its entirety, it is referred to for particular features in additional citations below.
• Improved orthoses described herein provide for more sophisticated rehabilitation procedures than previous instrumented orthoses. Referring toFIG. 1, certain embodiments of animproved orthosis100 include afirst support portion102, asecond support portion104, and athird support portion106 such that multiple joints can be supported byorthosis100.First support portion102 preferably is connected tosecond support portion104 by flexible connection/hinge108. Similarly,second support portion104 preferably is connected tothird support portion106 by flexible connection/hinge110. Control unit/controller112 can be connected to position sensors, described further below withinhinges108 and110 and to straingauges114,116. Alternative embodiments can include only one hinge or more than two hinges, with a correspondingly appropriate number of support portions.
• Support portions102,104,106 can be connected directly tohinges108,110 or by way oflinkers118,120,122,124. In particular,linker118 links supportportion102 withhinge108,linker120 links supportportion104 withhinge108,linker122 links supportportion104 withhinge110 andlinker124 links supportportion106 withhinge110.Linkers118,120,122,124 can have any desired rigid structure that is suitable given the structure of the support portion and the hinge.
• Other embodiments130 of the improved orthoses include hinges that provide for the motion of a joint in multiple planes. Referring toFIG. 2,first support portion132 andsecond support portion134 are connected tomultidimensional hinge136. As described further below,multidimensional hinge136 can include a plurality of single plane hinges or more complex structures.Support portions132,134 can be directly attached tomultidimensional hinge136 or by way oflinkers138,140, respectively.Orthosis130 preferably includes, at least, onestrain gauge142 to measure forces applied athinge136.
• A variety of constructions can be used for thesupport portions102,104,106,132,134 (FIGS. 1 and 2) such that a support portion properly supports the respective body portion. Referring toFIG. 3, afirst embodiment150 of a support portion hasframe members152 and154 that extend on either side of a body portion.Straps156 extend from oneframe member152,154 to the other to holdsupport portion150 in place around the corresponding body portion.Straps156 can be replaced with fabric sheets or other flexible or rigid connectors.Straps156 can be secured to framemembers152,154 with any of a variety of fasteners, such as snaps, buckles, clamps and hook and loop fasteners. The length ofstraps156 can be adjusted using conventional designs. A rope and pulley system can be used for tightening and looseningsupport structure150, as described further in application 60/098,779.Frame members152,154 connect directly to hingeelements158,160, although linkers can be used, if desired.
• Referring toFIG. 4, analternative embodiment166 of a support structure that surrounds the corresponding body portion.Support portion166 generally is somewhat rigid and can be constructed from a variety of materials. Preferred materials for the construction ofsupport portion166 include, for example, molded plastic shells, plaster, water-activated fiberglass, heat moldable thermoplastics, heat shrink plastic, and other cast forming materials.Support portion166 can be premolded in various sizes such that a particular size is selected “off-the-shelf'based on measurements of the patient. Alternatively,support portion166 can be constructed to provide a custom fit for a particular patient. These custom molded support portions are molded to fit the body portions of the particular patient by a trained physician or technician.
• Whether or not a linker is used to connect a particular support portion and a hinge, a hinge can involve just one or a plurality of distinct hinge elements, as appropriate. As used herein, a hinge element is a physically distinct structure that has two or more lever arms that rotate relative to each other. A hinge includes one hinge element if a support portion has a single lever arm connecting it by way of the hinge to the other support portion and more than one hinge element if a support portion has multiple lever arms at distinct locations of attachment to the support portion.
• For example, as shown inFIG. 2, hinge136 has a single hinge element, which corresponds to the hinge itself. In contrast, inFIG. 3 the hinge includes twohinge elements158,160. Similarly, inFIG. 1 eachhinge108,110 is depicted with two hinge elements. More than two hinge elements can be included in a single hinge, although it is preferably to use one or two hinge elements per hinge.Support structure166 inFIG. 4 can be attached to one hinge element or two hinge elements by direct attachment or using appropriate linkers. The hinge elements are placed such that the joint can rotate when the orthosis is properly placed around the joint and the hinge elements are not in a locked position.
• When forces are applied by the patient against the orthosis, the orthosis tends to change position relative to the patient's joint. This shifting reduces the effectiveness of any exercises being performed with the orthosis and may necessitate realignment of the orthosis for proper fit. The orthosis can be designed to reduce or eliminate this shifting.
• A first approach to prevent a knee orthosis from slipping during exercise is to construct the orthosis with indentations in the femur supracondylar area just above the knee. An alternative solution involves the use of additional securing cuffs. Securing cuffs are designed to be tightened more during exercise routines to help secure the orthosis relative to the joint. Securing cuffs include a gripping element and, for example, can be placed against the leg above the knee such that when tightened, the gripping element applies pressure above the kneecap and pushes on the knee without pushing on the vasculature and lymphatic drainage posteriorly. In other embodiments, the securing cuff can be appropriately placed.Cuffs270,272 can be tightened with a variety of fasteners including hook and loop fasteners.
• Another approach to securing the orthosis involves securing the orthosis to a belt by way of one or more straps. Still another approach involves reducing the friction of the surface contacting the orthosis or part of the orthosis, for example, using a high friction, polymer sleeve. Still another approach to securing the orthosis involves the placement of crossed straps behind the joint. The straps apply forces that tend to maintain the straps in the fold of the joint. Furthermore, for a knee orthosis, the orthosis can end with a heel cup or other support placed along the bottom of the foot. Such a foot support preferably includes a strap or the like around the foot to hold the bottom of the orthosis at the bottom of the foot and, thus, to fix the hinge roughly at the knee.
• With any of these approaches for inhibiting orthosis motion during use, the method preferably distributes the restraining forces sufficiently such that no portion of the skin is subject to excessive pressures that could bruise the skin as well as damage or interfere with neural or circulatory functions. Most of these approaches for preventing movement of the support portions are described further in the 60/098,779 application.
• Hinges108,110,136 (FIGS. 1 and 2) are intended to be interpreted broadly as any flexible connection that provides for angular motion of one support portion relative to another support portion.Hinges108,110,136 preferably can be locked at a selected angle to protect the joint from undesired motion and/or to provide for isometric exercises.Hinges108,110 can be mechanical, electromechanical or a combination thereof, as described further below. In preferred embodiments, the hinge/flexible connection includes a position sensor such that the relative orientation of the hinge can be measured and monitored by thecontroller112. For example, U.S. Pat. No. 5,052,375, to Stark et al. entitled “Instrumented Orthopedic Restraining Device and Method of Use,” incorporated herein by reference, discloses the use of a potentiometer-like mechanism used as a position sensor. Other suitable position sensors can be used, such as magnetic or optical sensors that are either digital or analog devices. Position sensing is useful for the evaluation of range-of-motion exercises and a variety of other exercises, as described further in the 60/098,779 application.
• An embodiment of a suitable mechanical hinge capable of locking and unlocking is shown inFIG. 5.Hinge180 includes a first engagingmember182 and a second engagingmember184.Members182,184 haveteeth186,188, respectively, that engage whenhinge180 is in a locked position.Knob190 is used to rotatebolt192. Second engagingmember184 includes a threadedscrew hole194 that is mated withbolt192 such that rotation ofknob190 movesknob190 relative tomember184.Spring196 tends to separatemembers182,184 from each other to the extent allowed by the relative position ofbolt192 within threadedhole194.Clip198 withinrecess200 prevents separation ofbolt192 frommember184. Referring toFIG. 6,strain gauges202 are located onframe204.Frame204 can be a linker betweenhinge180 and a support portion or a component of a support portion.
• Referring toFIGS. 5 and 6, hinge180 includes a position sensing device in the form of a variable resister. In particular,member184 includes twoflexible wiper arms210,212.Wiper arms210,212 are in electrical contact with each other such that current can flow between them.Flexible wiper arm210contacts resistance element214, whileflexible wiper arm212contacts conducting element216.Resistance element214 and conductingelement216 have an electrical potential difference between them.Resistance element214 has anelectrical connection218 at one end such that the electrical resistance resulting from current flow throughresistance element214 depends on the position ofwiper arm212 as determined by the relative angular orientation ofmember184 relative tomember182.Wires220 provide for electrical connection ofresistance element214 and conductingelement216 directly or indirectly tocontroller112.
• Referring toFIG. 7, anelectromechanical hinge240 is shown.Hinge240 includes afirst element242, which connects to afirst support portion244, and asecond element246, which connect to asecond support portion248.Second element246 connects withaxle250, which rotates withinshaft252 such thatsecond element246 can rotate relative tofirst element242.Axle250 is secured withnut254.Shaft252 passes througharmature256.Armature256 is held withincase258.Case258 is secured tofirst element242.
• Lead270 electrically connectsstator coil272 withinstator housing274 with a current source.Stator coil272 is designed to attractarmature256 when sufficient magnetic field is generated by electric current flowing throughstator coil272. The current can be supplied fromcontroller112. Whenarmature256 is attracted tostator coil272, a pair offree riding discs276,278 are gripped betweenarmature256 andstator housing274. Outer disc276 is made preferably from a suitable metal, andinner disc278 is made preferably from a suitable polymeric material to provide for a smooth grip between the surfaces and to prevent wear between the surfaces. Aspring280 biases armature256 away fromstator housing274 when the magnetic attraction betweencoil272 andarmature256 is insufficient to overcome the forces ofspring280. Sufficient attraction betweencoil272 andarmature256 locksfirst element242 relative tosecond element246.
• In preferred embodiments, a hinge provides selectable resistance to rotation for the performance of isotonic exercises. For example in the embodiment ofFIG. 7, lesser amounts of attraction betweencoil272 andarmature256 can result in selectable amounts of resistance/friction in the rotation offirst element242 relative tosecond element246. The selectable resistance can be adjusted withcontroller102 by varying the current supplied bycontroller102 tostator coil272.
• Referring toFIGS. 7 and 8, a position sensor/variable resistor includes aresistance element290 andwirer arm292.Resistance element290 is connected tocase258.Wiper arm292 is keyed to rotate withaxle250 such that rotation ofsecond element246 relative tofirst element242 rotateswiper arm292 to different angular positions alongresistance element290.Conductor arm294 provides current to wiperarm292. Conductor arm is electrically insulated relative tocase258 while providing electrical connection by way ofconnection296.Resistance element290 is connected toelectrical connection298. Resistance measurements can be made by way ofconnectors296,298. Resistance measurements are a function of the angular position ofsupport portion244 relative tosecond support portion248.
• Mechanical and electromechanical hinges are described further in U.S. Pat. No. 5,484,389 to Stark et al., incorporated herein by reference. In particular, a suitable electromechanical hinge with variable resistance controllable by way ofcontroller112 is described further in published PCT application WO 96/36278, entitled “An Orthopedic Device Supporting Two or More Treatment Systems and Associated Methods,” incorporated herein by reference.
• A preferred embodiment of a left,mechanical hinge300 is shown inFIG. 9. This hinge has a construction that provides for particularly easy release of the lock by a patient with one hand. The orientation of the hinge is measured by a position sensor to assist the patient in resetting the lock at a desired orientation. A right hinge would be the mirror image of the hinge inFIG. 9.
• Hinge300 includes aouter plate302,washer304, lockingunit306,ring lever308,electrical resistance disc310 andinner plate312.Outer plate302 is connected to aframe member318.Strain gauge319 can be attached toframe member318.Outer plate302 andinner plate312 include concentric stop holes320, bolt holes322, connection holes324 andslot326. The corresponding holes are aligned between leftouter plate302 andinner plate312.
• One or two stop pins can be placed through two aligned stop holes320 inouter plate302 andinner plate312 to define limits of hinge rotation. Bolts or other fasteners are secured throughbolt holes322 to holdhinge300 together.Electrical resistance disc310 rests within a hollow338 withininner plate312.Electrical resistance disc310 makes electrical contact withwire340.
• Lockingunit306 includescontrol disc346,slider348,slider spring350 and lock-out latch352.Control disc346 includes bolt holes322 and aslit354 in whichslider348 slides.Slider348 has agroove356 and anindentation358 with acatch360. Lock-out latch352 has a knob362 and abar364. Bar364 slides withinslots326 and can fit withingroove356 to holdslider348 in a depressed, unlocked, position.
• Ring lever308 is connected with aframe member370.Ring lever308 has anopening372 with a diameter slightly larger than the diameter ofcontrol disc346 such thatcontrol disc346 can fit withinopening372.Control disc346 preferably has a thickness slightly larger thanring lever308. A set of concentric, notches374 are located around the edge of opening372 ofring lever308. Catch360 ofslider348 fits within the notches374 to lock the hinge at a particular orientation whenslider348 is in an extended position.Depressing slider348 against the force ofspring350 disengages catch360 from one of the notches374 such thathinge300 is free to rotate within the bounds establishes by any stop pins.Ring lever308 includes anelectrical contact376 set within ahole378 that contactselectrical resistance disc310. Electrical contact476 is connected bywire380 tocontroller112 or alternative resistance meter.
• Outer plate302,inner plate312,ring lever308,control ring346, lock-out latch352 andslider348 preferably are made from rigid, durable materials. In particular,outer plate302 andinner plate312 are preferably made from an aluminum alloy, andring lever308,control ring346, lock-outslide352 andslider348 preferably are made from stainless steel.Spring350 generally would be made from resilient steel or the like.Washer304 and stop pin330 generally are made from polytetrafluoroethylene or the like.Electrical resistance disc310 can be made from circuit board material with a resistance element screen-printed on its surface.
• Frame members318 and370 extend fromhinge300 such that movement offrame member318 relative to framemember370 involves rotation ofhinge300. Whenhinge300 rotates,outer ring302 andinner ring312 rotate relative to ringlever308.Outer ring302,inner ring312 andcontrol disc346 are held fixed with respect to each other by way of bolts passing through bolt holes322. The orientation ofhinge300 is locked unlessslider348 is depressed such thatcatch360 is withdrawn fromnotches372. Lock-outslide352 can holdslider348 in the depressed, unlocked position. The position ofring lever308 relative toinner ring312 can be measured by way of the position ofelectrical contact376 alongelectrical resistance disc310. The relative position ofelectrical contact376 alongelectrical resistance disc310 provides a variable electrical resistance useful for position/orientation sensing.
• It may be convenient to provide for release of a hinge with a remote control. The release of an electromechanical hinge using a command from the controller is described above. It may be desirable to have a simple mechanical remote release. A simple photographic shutter release can be adapted for this purpose with the hinge ofFIG. 9. The shutter release can be screwed at its threaded tip intohinge300 at threadedhole394 incontrol ring346. Pressing the plunger of the cable release advances a cable, which in turn depressesslider348 thereby unlockinghinge300. Alternative designs for mounting of a manual hinge release involve pulling a plunger that in turn pullsslider348 such that the lock is disengaged and such that releasing the plunger reestablishes the hinge lock.
• While electronic control of the resistance in a flexible connection/hinge has advantages, cost and design simplicity favors a purely mechanical hinge. Referring toFIG. 10, With a purely mechanical hinge, such as shown inFIG. 5, strain gauge readings can be accurately calibrated to reflect the forces applied to move the hinge against a setting on a mechanical resistance applicator. Thus,control unit112 can be used to monitor the isotonic exercises even though the resistance is not electronically controlled. A mechanical resistance applicator can be made integral with the hinge, but in preferred embodiments the resistance unit can be separated from the hinge such that no resistance is applied to the hinge when resistance is not desired. A resistance applicator can designed to amplify small changes in the resistance that correlate with easily made changes in the position of a knob.
• Referring toFIG. 10, a cross section through the center of an embodiment ofresistance applicator400 is shown.Resistance applicator400 includeshousing404, acrank406, acompression structure408,knob410, bearingunit412,washer414 andspacers416.
• Housing404 includes lock pins428. A second lock pin is not shown in the sectional drawing. Lock pins328 provide releasable connection for attachment ofresistance applicator400 to a hinge, such ashinge300 ofFIG. 9. In particular, lock pins428 ofresistance applicator400 can be secured throughconnection holes324 to releasablysecure resistance applicator400 in an operable position with respect to hinge300. Alternative locking approaches can be used for the attachment of the friction applicator to the hinge.Housing404 includes threadedhole432 for engagingknob410.Housing404 further includescylindrical protrusion438 for engagingcompression structure408.
• Crank406 includescylindrical extension454 for engagingcompression structure408 andpads458, which engage a support portion, such that rotation of the hinge of the orthosis rotates crank406 relative tohousing404.
• Compression structure408 provides for small changes in the resistance due to changes in the distance betweenwasher414 andhousing404 asknob410 is rotated, thus amplifying resistance changes by way of the knob.Compression structure408 generally produces friction as a result of shear forces withincompression structure408 due to relative motion ofhousing404 and crank406. In one embodiment,compression structure408 includes alternating crank discs and housing discs to form a multiple clutch plate. Crank discs engage crank406, such that the crank discs rotate withcrank406. Housing discs have a central hole shaped to engageprotrusion438 inhousing404, such that housing discs rotate withhousing404.
• Knob310 includes a threadedshaft482 with threads and diameter suitable for engaging the threads of threadedhole432 inhousing404.Bearing unit412 preferably includes a ring of ball bearings in a bearing case.Bearing unit412 can be replaced with other bearing structures or other friction reducing approaches such as hydro bearings.
• Washer414 has a suitable inner diameter such that threadedshaft482 can pass through the inner diameter but bearingunit412 cannot pass.Washer414 has an outer diameter such thatwasher414 rests onextension454 ofcrank406 covering the opening tocompression unit408 betweenhousing404 and crank406. Two optional spacers preferably are located with one on each side ofcompression unit408. The spacers have the shape of a washer but with a suitably larger inner diameter and smaller outer diameter thanwasher414 such that the spacers fit within the cavity between crank406 andhousing404.
• The primary components of theresistance applicator400 preferably are made from metals and/or alloys. Aluminum alloys and stainless steel are suitable metals for the construction of housing and crank components. Rigid polymers can be used in place of metals for the housing and crank elements. The spacers preferably are made of brass. The housing disc preferably is made from spring steel, and the crank disc preferably is made from spring tempered phosphor bronze. The bearing case can be made from Nylon®.
• Resistance applicator400 is designed to attach to a hinge such thathousing404 moves with a frame member attached to one side of the hinge while crank406 moves with a frame member attached to the other side of the hinge. Thus, rotation of the hinge results in rotation ofhousing404 relative to crank406. Tightening ofknob410 presseswasher414 down ontocompression unit408. Housing rings and crank rings rotate relative to each other whenhousing404 moves relative to crank406. Increasing the pressure oncompression unit408 results in increased resistance in the rotation ofhousing404 relative to crank406 because of friction between housing rings and crank rings. This design provides for sensitive adjustment rotational resistance by rotation ofknob410. Theimproved hinge300 shown inFIG. 9 combined with theimproved resistance applicator400 is described further in the 60/098,779 application.
• In alternative embodiments, a hinge takes the form of an articulatinghinge490, as shown inFIG. 11. Articulatinghinge490 can be made with resilient collapsible materials such as a bendable straw, sliding sections that can slide past each other to articulate, or other similar constructions. Sliding sections can be locked relative to one another by way ofclamps492 attached toslots494 defining a range of motion, where the clamps are tightened manually with wing nuts or the like, or electronically with solenoids or the like. As shown inFIG. 11, articulatinghinge490 is connected to twosupport portions166 that surround the corresponding body portions. Alternatively, one or bothsupport portions166 can be replaced with other types of support portions or by linkers that connect the support portions to hinge490.
• Certain joints such as the knee are cams that do not involve rotation about a single axis. A biaxial hinge can be used to more closely approximate the motion of the joint cam. Abiaxial hinge500 generalizing on the structure ofhinge300 is shown inFIG. 11.Biaxial hinge500 includes aproximal arm502 and adistal arm504.Proximal arm502 includes teeth, which engage teeth ondistal arm504.Proximal arm502 further includes lock notches and an electrical contact for position (orientation) sensing. A control ring operates similarly to controlring346 inhinge300 to control the locking/unlocking of the hinge. Further details onbiaxial hinge500 can be found in the 60/098,779 application.
• Orthosis130 shown inFIG. 2 includeshinge136 capable of rotation in multiple planes to provide for multiple ranges of motion about a single joint. A first embodiment of a hinge capable of motion in multiple planes is shown inFIG. 13 and an exploded view inFIG. 14.Hinge510 includesrod512 that moves withinsleeve514.Sleeve514 has fourresilient sections516 that form a truncated conical shape.Sleeve514 further hasthreads518.Cap520 fits over and screws ontosleeve514.Cap520 includesworm gear threads522.Lever524 has matedworm gear threads526 to complete the worm gear withlever524adjacent cap520.
• Cap520 can be screwed to varying degrees to increase or decrease the tension atresilient sections516. Tension atresilient sections516grips rod512 to a corresponding degree. The wormgear comprising threads522 and526 can be used to screwcap520 on to or off fromsleeve514. The worm gear is advanced by the rotation oflever524.
• Hinge510 moves in two degrees of freedom, with one degree of freedom corresponding to therod512 moving into or out fromsleeve514. The rotation ofrod512 provides motion in the second degree of freedom. Screwingcap520 sufficiently locks both degrees of freedom. Hinge510 can be incorporated into a shoulder orthosis such that motion of therod512 into and out fromsleeve514 provides for movement of the patient's elbow toward or away from the torso while rotation ofrod514 provides for movement of the arm toward the front or toward the rear.
• In preferred embodiments, hinge510 includes position sensors such that the orientation in each degree of freedom can be measured. In one embodiment,rod512 includes aresistive element530 that can be used to contact a conductive brush withinsleeve514.Resistive element530 can be used to measure the position ofrod512 as it projects to varying degrees withinshaft512. Slimily,rod512 can further include aconductive brush532 that contacts a resistive element. Brush512 can be used to measure the orientation ofrod512 depending on the rotation ofrod512 withinsleeve514.
• A secondmultidimensional hinge540 is displayed inFIG. 15.Hinge540 includes afirst hinge542 attached to afirst lever arm544. Asecond lever arm546 linksfirst hinge542 withsecond hinge548. Rotation about the first hinge involves relative rotational motion offirst lever arm544 relative tosecond lever arm546 andsecond hinge548.Third lever arm550 is attached tosecond hinge548, such that rotation aboutsecond hinge548 rotatessecond lever arm546 relative tothird lever arm550.
• Preferably,first hinge542 andsecond hinge548 are separately lockable, and, optionally, have adjustable resistance. Designs for single plane hinges described above can be used forfirst hinge542 andsecond hinge548. These hinges have position sensors, such that the orientation of each hinge can be measured.Multidimensional hinge540 can be used advantageously in orthoses for joints that move in multiple planes. For example, hinge540 can be used in a shoulder brace where one oflever arms544 and550 moves with the patient's arm while the other is fixed to their abdomen.
• Strain gauges114,116,142 can be useful for the performance of both isometric and isotonic exercises. Strain gauges can be placed at any suitable location such that the strain in the underlying material reflects the torque applied between two respective flexibly connected body portions surrounding the joint of interest. Suitable locations for the strain gauges involve placement of the strain gauges on a structure that is attached to the corresponding hinge. The strain gauges generally are located on a rigid element near the hinge that is under stress when torque is applied to the hinge. Since different structures have different relationships between the support portions and the hinge, the preferred locations for the strain gauges depend on the particular construction of the orthosis.
• Whether monitoring isometric exercises or isotonic exercises, strain measurements obtained by way of a strain gauge can be correlated with the corresponding forces applied by the patient. Strain gauges114,116 are connected tocontroller112, which evaluates the strain based on the electrical properties of the strain gauge. Suitable strain gauges are available from Vishay Micromeasurements Group (Raleigh, N.C.) (e.g., type 125AD, part number EK-XX-125AD-350 with dual copper pads), or JP Technologies (San Bernardino, Calif.). Evaluation of the strain is discussed further below in the context ofcontroller112.
• As noted above, for a variety of treatments, it is useful to incorporate an instrumented hand hold. Referring toFIG. 16, a hand hold600 is mounted on top of asupport602.Support602 projects from aarm rest604.Support602 should have a height for comfortable gripping of hand hold600. In preferred embodiments,arm rest604 forms part of an instrumented orthosis that, at least, extends past a patient's elbow.Arm rest604 can be part of a shoulder brace, as described further below. Hand hold600 can have any comfortable shape for gripping, such as spherical or cylindrical.
• As shown inFIG. 17,arm rest604 can include awrist hinge606.Wrist hinge606 preferably includes a position sensor, a position lock and adjustable friction, as described above with respect to preferred embodiments of various hinge designs. Hand hold600 rests on a hand support608 that connects to armrest604 throughwrist hinge606. As shown inFIG. 17, hand hold600 rests on hand support608 without elevation with asupport602.
• Hand hold600 can be a bladder filled with a fluid, such as a gas, liquid or a pseudo-liquid formed by a granular material or the like. Alternatively, hand hold600 can be formed from a compressible material, such as a foam or the like. The degree of compressibility can be selected to obtain a suitable amount of exercise from hand hold600. If hand hold600 is filled with a fluid, hand hold600 can include one ormore valves610.Valve610 can be used to add or remove fluid from hand hold600 to vary the nominal pressure in ball600.
• Hand hold600 preferably includes apressure sensor612 or a strain gauge.Pressure sensor612 can be used to measure the amount of force applied by a patient when squeezing hand hold600. When hand hold600 is squeezed, the pressure increases in hand hold600, if hand hold600 contains a fluid. A strain gauge measures forces applied to squeeze ball600 according to the increased strain along the surface of ball600.Pressure sensor612 and/or a strain gauge generally are connected tocontroller112 bywire614.
• Suitable strain gauges were described above.Pressure sensor612 can be any reasonable type. A variety of suitable pressure sensors are commercially available. Preferred pressure sensors include the MPX series of pressure sensors manufactured by Motorola because of their linear output and small size, and NPP 301A from Lucas Novasensor, Fremont Calif., which are small and inexpensive. Other suitable pressure sensors use silver oxide ink surfaces separated by a dielectric material or piezoelectric materials that produce a voltage when stressed.
• In an alternative embodiment, the orthosis includes ahand grip630, as shown inFIG. 18.Hand grip630 can be mounted in the same way with respect to anarm support604 as squeeze ball600.Hand grip630 includes finger rests632. Finger rests632 are indentations that provide a specific location for resting each finger. In preferred embodiments,hand grip630 includes pressure sensors/strain gauges634 in the vicinity of eachfinger rest632. Pressure sensors/strain gauges634 can be used to measure the force approximately corresponding to the force applied by a particular finger. Pressure sensors/strain gauges634 are connected tocontroller112 by way ofwires636.
• Hand grip630 generally includes some compartmentatization such that forces applied by one finger are approximately segregated in effect within a corresponding compartment. Thus, ifhand grip630 includes a fluid or fluids, the fluids can be placed within separate compartments for each finger, preferably separated by a relatively rigid barrier. Similarly, a compressible material, e.g., a foam, supporting each finger can be similarly separated by a relatively rigid barrier.
• An instrumented orthosis can be configured to delivery one or more monitored, therapeutic energy treatments along with the capability of performing monitored exercise. The therapeutic energy is delivered by way of an energy transducer. Suitable types of energy transducers include, for example, ultrasonic transducers, pulsed electromagnetic field transducers, implantable electrical current transducers, surface electrical current transducers, and electrical muscle contraction stimulator. The transducers are located at an appropriate position to provide treatment for the injured area. The transducers preferably are controlled and monitored bycontroller112. Further discussion of combined treatment approaches using exercise and/or energy propagating transducers are described in published PCT application WO 96/36278, entitled “An Orthopedic Device Supporting Two or More Treatment Systems and Associated Methods,” incorporated herein by reference.
• In simplified embodiments,controller112 may just include analog circuits and a suitable display. In preferred embodiments,controller112 includes a digital processor to provide a more sophisticated interface with the patient and/or with a health care professional and to perform more involved monitoring functions. The digital processor preferably is a microprocessor. The digital processor can be programmed in any of a variety of computer languages including, for example, basic, assembler, C, C++ and the like. Preferably, controller232 is portable, which in this context means that the controller is small enough to be ambulatory with the patient. More preferably,controller112 is small enough to be held in the hand of a patient, and even more preferably to be placed in a standard shirt pocket.
• A preferred microprocessor basedcontroller112 has several subsystems including a power supply such as a battery, a transducer bias circuit such as described below, A/D converters, a microprocessor, real time clock, RAM and non-volatile storage such as FLASH, SRAM or EEPROM, a graphic display such as a 64×128 pixel LCD display with a corresponding driver, keypad, audible or tactile feedback device, data link to transducer, and an integral modem or RS232 standard output for serial connection or modem access.
• In one particular embodiment, the microprocessor is a Motorola MC68HC11A1FN 8-bit microcontroller with built-in deep sleep shutdown mode for power conservation between active events, a programmable serial interface and an 8-channel, 8-bit A/D converter. In this embodiment, controller232 can provide analog multiplexing and A/D conversion for up to 8 analog input signals over a voltage range from 0.0 to +5.0 volts. For example, three of the channels can be devoted to provide signal conditioning for up to three strain gauges, and three of the channels can be devoted to providing signal conditioning for up to three position (angle) sensors. The remaining two input channels then can be used for additional treatment devices. If desired, added sensors can be handled by multiplexing and duty-cycling.
• In this preferred embodiment, the controller module memory includes SRAM, FLASH and EEPROM, where each section is independently addressable. Each section can support, at least, 32K words with 8-bits (1 byte) per word. The EEPROM supports in-circuit reprogramming by way of the microcontroller serial channel for code updates. The FLASH memory provides non-volatile storage of recorded data. The real time clock is battery powered to allow time keeping to continue when the microcontroller circuitry is off The real time clock is capable of generating periodic interrupts at a programmable rate to power switching circuitry to activate the microcontroller during an alert mode of operation.
• The RS-232 interface consists of three conductor (T×D, R×D and GND) jack type connector with a mechanical switch to automatically switch power on to all on-board electronics when the plug is inserted. The baud rate of the interface is programmable with standard rates such as 9600 and 19200. A suitable display is a Densitron™ LE3328 LCD with Hitachi HD61202 and HD61203 LCD controller chip sets. The display can be run with a five volt supply that can be separate or not from the power supply for the rest of controller232. In this embodiment, a three key keypad is interfaced with the microcontroller.
• All of the components ofcontroller112 can be placed on the orthosis or in a separate case. The components ofcontroller112 can be integrated into a single package or physically partitioned into portions mounted on the orthosis frame and/or portions placed into one or more small cases.
• Controller112 preferably stores a software program that manages the use of the device for patient rehabilitation. The software can provide for alerting the patient to scheduled times for the performance of exercises using audible and/or vibratory signals.Controller112 preferably provides instructions on the exercises as well as feedback and reinforcement messages to the patient. The software preferably is custom programmed for the patient by a health care professional based on an evaluation of the patient's condition. Approaches for programming the control unit is described further in the 60/098,779 application.
• Stored information relating to the patient's performance of exercises generally is downloaded to the supervising health care professional at specified intervals. The download of the information can be performed in a variety of ways. If the patient goes to the office of the health care professional,controller112 can be directly connected to the monitor station/computer using the RS232 port or other port using suitable protocols including standard protocols. Alternatively,controller112 can be attached to a modem by way of the RS232 port or other suitable port. Since with certain embodiments the file sizes are relatively small, a single chip, 9 volt supply Rockwell® 2400 baud or 9600 baud modem can be used.Controller112 can be in radio communication with a monitor station.Controller112 then would include a radio transmitter and, optionally, a receiver. Radio communication with a monitor station is described further and U.S. Pat. No. 5,823,975 entitled “Local Monitoring System For an Instrumented Orthopedic Restraining Device and Methods Therefore,” incorporated herein by reference. The display or a television set similarly can be in communication withcontroller112 by way of radio transmissions or infrared communication such that a wire attachment is not necessary. Additional features of the controller are describe in the 60/098,779 application.
• In order for the value of electrical resistance associated with a strain gauge to be useable as a measure of applied stress during isometric exercises, the values must be referenced to a “null” valve approximately corresponding to a value when no strain is applied to the orthosis. The null value can be set by a manual adjustment performed by the health care professional or by the patient. The “null” value, however, is preferably established automatically without the need for calibration by the user. Furthermore, the variations in the resistance due the strain gauge preferably are converted into a voltage value that is amplified to make efficient use of an analog-to-digital (A/D) converter with a specified number of binary digits. A preferred summing amplifier circuit for calibrated strain gauge measurement is described in detail in the 60/098,779 application.
• Further aspects of the improved orthoses are illustrated by reference to three particular preferred embodiments.
• A. Shoulder Brace
• Referring toFIG. 19, a preferred embodiment of ashoulder brace700 includestrunk support702, underarm support704, upright support706,shoulder hinge708,arm support710,elbow hinge712,fore arm extension714 andcontroller716.Trunk support702 includes a paddedhip rest730 contoured to rest comfortably against a patient's hip and distribute any downward forces over a reasonable area.Padded hip rest730 can include a relatively rigid shell, made from fiber glass, polytetrafluorethylene other suitable polymers, metal or the like. Padding, such as cloth covered foam padding, can be placed adjacent the rigid shell.Trunk support702 generally further includes astrap732, which can wrap around a patient's waist to securetrunk support702.Strap732 preferably has an adjustable length,optional padding734 and afastener component736, such as a portion of a hook-and-loop fastener, a buckle or any other suitable fastener component. Asecond fastener component738 is attached to a strap or directly to paddedhip rest730, as desired.Second fastener component738 is the complement tofastener component736, such thatfastener components736,738 can be secured to each other.
• Underarm support704 includes a paddedsupport portion740, which can include a relatively rigid shell with padding located along the inner and/or upper surface. Underarm support704 further includes astrap742, which can wrap around a patient's chest to secure underarm support704.Strap742 has anoptional pad744, and preferably has an adjustable length and a fastener component746. Asecond fastener component748 can be attached to another strap or directly to paddedsupport portion748.Fastener components746,748 can be complementary components of a buckle fastener, a look-and-loop fastener, or any other suitable fastener. Underarm support704 further includes ashoulder strap750.Shoulder strap750 can includepadding752, and preferably has an adjustable length. In this embodiment,shoulder strap750 extends fromstrap742 to paddedsupport portion740, although other configurations are possible.Shoulder strap750 is designed to extend over the opposite shoulder of the patient relative to the shoulder supported by underarm support704.
• Upright support706 connects paddedhip rest730, paddedsupport portion740, andshoulder hinge708. Upright support can be constructed from any rigid material such as metal, fiber glass or other rigid material or materials. Upright support706 can be bolted to paddedhip rest730 and paddedsupport portion740, molded into a rigid shell of paddedhip rest730 and paddedsupport portion740, or secured to paddedhip rest730 and paddedsupport portion740 in any other reasonable fashion. Upright support706 can attach directly to a lever arm ofshoulder hinge708 or through a linking element connecting upright support706 to a lever arm ofshoulder hinge708. Upright support706 holds paddedhip rest730, paddedsupport portion740 andshoulder hinge708 at constant relative positions.
• Shoulder hinge708 preferably is a hinge capable of motion in multiple planes. Suitable designs for hinges with releasable motion in multiple planes for use asshoulder hinge708 are described above. As noted above, upright support706 is attached to one lever arm ofshoulder hinge708. A second lever arm ofshoulder hinge708 is attached toarm support710.
• Arm support710 preferably includes asupport brace760 and paddedarm support762.Support brace760 is attached to a lever arm of should hinge708 and to a lever arm ofelbow hinge712, either directly or through a linker.Padded arm support762 is connected to supportbrace760. Padded arm support helps the patient hold their arm in a proper position alongsupport brace760.
• One lever arm ofelbow hinge712 is connected to supportbrace760 and a second lever arm ofelbow hinge712 is connected tofore arm extension714.Elbow hinge712 is oriented such that rotation at the patient's elbow results in rotation of the hinge, ifhinge712 is in an unlocked setting and the patient's arm is properly located alongarm support710 andfore arm extension714 with their handgripping hand hold774.Elbow pad764 is attached to elbowhinge712 orsupport brace760. If desired, the lengths ofarm support710 and/orfore arm extension714 can be adjustable.
• Fore arm extension714 includesextension shaft770,bend772 and hand hold774.Shaft770 can be made adjustable, such that the distance from the elbow to the hand can be set to an appropriate value.Bend772 connectsshaft770 withhand hold774. Hand hold774 preferably is a padded grip. Bend772 preferably is connected toshaft770 by way of awrist hinge776.Fore arm extension714 preferably includestraps778 to secure the patient's arm. The hinge shown inFIG. 9 can be adapted for use aselbow hinge712 andwrist hinge776.
• Shoulder brace700 preferably includes a plurality of transducers. As depicted inFIG. 19,strain gauges780,782 are associated with upright support706 andsupport brace760, respectively. Strain gauges780,782 can supply measurements related to forces applied against a locked hinge or forces applied for rotation ofshoulder hinge708 and/orelbow hinge712.Shoulder hinge708 preferably includes amultidimensional position sensor784, as described above.Elbow hinge712 preferably includes a position sensor,786. Furthermore, hand hold774 can include one or more pressure/stress transducers788, to provide measurements related to forces applied by the patient's hand.
• The transducers are preferably connected tocontroller716, generally by wires, although transmitter based approaches can be used. Suitable designs forcontroller716 were described above with respect tocontroller112 ofFIG. 1. Straightforward modifications can be made to accommodate all of the transducers desired forshoulder brace700.
• To useshoulder orthosis700, a patient can slipshoulder strap750 over their arm and head. With the weight of shoulder brace supported onshoulder strap750,straps732 and742 can be secured to distribute the weight and balance ofshoulder brace700 over the various support segments. Withbrace700 secured to the patient's torso, the patient can position their arm alongarm support710 with their appropriate handgripping hand hold774.Shoulder brace700 can serve as a support for the patient's back, shoulder, elbow, wrist and/or hand. Furthermore, shoulder brace provides for a variety of exercises to assist with the recovery of an upper body injury, and/or to prevent the deterioration from lack of use of joints near an injury. Potential exercise programs are described further below.
• B. Lower Extremity Full Leg Brace
• Referring toFIG. 20, a particular embodiment of afull leg brace800 includeswaist support802,hip hinge804,thigh support806,knee hinge808,shin support810,ankle hinge812, ankle/foot support814,foot rest816 andcontroller818.Waist support802 preferably secures at the patient's waist to support the upper portion offull leg brace800.Waist support802 can have a similar design astrunk support702, described above.Waist support802 generally includessupport section820 and hingelink822.Support section820 can be formed from one or more segments of rigid shell with inner padding to cushion contact with the patient. Multiple rigid shell segments can be connected with flexible segments for easier fastening around the patient's waist. Waist support includesstraps824 or the like to provide for easy fastening and unfastening ofwaist support802.Hinge link822 provides for rigid connection ofsupport section820 withhip hinge804.
• Hip hinge804 preferably is a hinge capable of motion in multiple planes. Suitable instrumented hinges with motion in multiple planes were described above. Preferred hip hinges804 provide for motion of the leg forward-to-back as well as side-to-side, when the hinge is unlocked.
• Thigh support806 includes ahinge link830, asupport segment832 andframe members834,836.Hinge link830 provides rigid support betweenhip hinge804 andsupport segment832.Support segment832 preferably encircles the patient's thigh, to securethigh support806.Support segment832 generally includes rigid shell segments with padding. In preferred embodiments,support segment832 includes flexible segments connecting rigid shell segments. One or more flexible segments preferably include areleasable fastener838, such as a hook-and-loop fastener to provide for easy fastening and unfastening ofsupport segment832.Frame members834,836 provide rigid connection betweensupport segment832 andknee hinge808.Frame members834,836 can be designed to have adjustable lengths to provide a proper fit.
• In this embodiment,knee hinge808 includeshinge elements840,842, connected, respectively, to framemembers834,836. Several suitable designs for instrumentedhinge elements840,842 are described above.Hinge elements840,842 connect toshin support810, such thatshin support810 andthigh support806 connect to different lever arms of eachhinge element840,842.
• Shin support810 includesframe elements850,852 andstraps854,856,858,860 connected to frameelement850.Frame elements850,852 connect withhinge elements840,842, respectively. The patient's leg rests betweenframe elements850,852.Straps854,856 connect over the front of the patient's leg, whilestraps858,860 connect behind the patient's leg.Straps854,856,858,860 can include padded portions.Straps854,856,858,860 generally have an adjustable length and includefastener element862,864,866,868. Matchedfastener elements870,872,874,876 are connected to frameelement852 directly or with straps.Fastener elements870,872,874,876 can be elements of a clip, a buckle, hook-and-loop fastener or other suitable fastener.Fastener elements870,872 and874,876 together can be single sheets of hook or loop material of a hook-and-loop fastener.
• In this embodiment,ankle hinge812 includeshinge elements880,882, connected respectively to frameelements850,852. Several suitable designs for instrumentedhinge elements880,882 are described above.Hinge elements880,882 connect to ankle/foot support814, such that ankle/foot support814 andshin support810 connect to different lever arms of eachhinge element880,882.
• Ankle/foot support814 includesframe segments884,886.Frame segments884,886 connect withhinge elements880,882, respectively.Frame segments884,886 further connect withfoot rest816. Frame segments can be made adjustable such that the distance fromhinge elements880,882 tofoot rest816 can be adjusted to the proper length for the patient.
• Foot rest816 includes aheel support890 andfoot strap892.Heel support890 is contoured to the fit the rear portion of a patient's foot.Foot strap892 wraps around the patient's foot to secure the patient's foot againstheel support890.Strap892 preferably has an adjustable length to obtain a proper fit.Foot strap892 includes afastener portion894 that connects with matedfastener portion896.Fastener portion896 generally is connected toheel support890 on the opposite side relative to the connecting point offoot strap892.Fastener portions894,896 can be portions of any suitable fastener, such as buckles, clasps, hook-and-loop fasteners and the like.
• Full leg brace800 preferably includes a plurality of transducers. As depicted inFIG. 20,strain gauge900 is associated withhinge link822.Strain gauge902 is associated withframe member834.Strain gauge904 is associated withframe segment884. Strain gauges900,902 and904 can supply measurements related to forces applied against a locked hinge or related to rotation ofhip hinge804,knee hinge808, and/orankle hinge812.Hip hinge804 preferably includes a multidimensional position sensor906, as described above.Hinge element840 ofknee hinge808 preferably includes a position sensor,908, to measure the orientation ofknee hinge808. Similarly, hinge element880 ofankle hinge812 preferably includes a position sensor,910. Furthermore,heel support890 can include one or more pressure/stress transducers898, to provide measurements related to forces applied by the patient on their heel.
• The transducers are preferably connected tocontroller818, generally by wires, although transmitter based approaches can be used. Suitable designs forcontroller818 were described above with respect tocontroller112 ofFIG. 1. Straightforward modifications can be made to accommodate all of the transducers desired forfull leg brace800.
• The brace shown inFIG. 20 is intended to be worn on the patient's left leg. A corresponding brace can be constructed for the patient's right leg based on this design by connecting the leg portion of the brace to the other side ofwaste support section820. The leg portion can be identical in construction to the left leg version shown inFIG. 20, or the leg portion can involve reversal of the left and right hand elements on the leg portion, such that the resulting right leg portion corresponds to the left leg portion reflected through a symmetry plane going through the center of the leg portion. Furthermore, a lower extremity brace that supports both of the patient's legs can be constructed with a singlewaste support section820 connected through two hip hinges804 to appropriate supports for both legs.
• For use, fillleg brace800 is placed around the patient's leg with the foot supported byfoot support816, withwaist support802 secured at the patient's waist, andsupport segment832 secured around the patient's thigh.Straps854,856,858,860 and892 are appropriately fastened to fully supportfill leg brace800.Full leg brace800 can be used to provide valuable support for the patient as well as for the performance of a variety of monitored, programmed exercises, as described further below.
• C. Stroke Brace
• Preferred embodiments of a stroke brace have upper body and lower extremity support. For the most common stroke debilitation, i.e., hemiparesis affecting one whole side of the body, the shoulder brace and fill leg brace described above can be combined.Shoulder orthosis700 ofFIG. 19 can be used along with lower extremities orthosis800 ofFIG. 20. In these embodiments, a common trunk support is substituted fortrunk support702 andwaist support802. The common trunk support is straightforward to design by incorporating the features oftrunk support702 andwaist support802.
• With respect to instrumentation, transducers fromorthoses700,800 can be connected toseparate controllers716,818, or the transducers preferably can be connected to a single controller adapted to accommodate all of the transducers of both orthoses.Shoulder orthosis700 can be physically connected to lower extremities orthosis800 for stability, ororthoses700,800 can be physically disconnected except for possibly connection to a single controller.
• 2. Rehabilitation Using Orthoses
• The controllers described above preferably are programmed under the supervision of an appropriate health care professional. In one preferred embodiment, the controller has four modes of operation: OFF, STANDBY, ALERT and FULL ON. In the OFF mode, primary and backup battery power are removed, and no operations are taking place in the controller. In the STANDBY mode, no primary battery power is online, and backup battery power is used to maintain the real time clock and SRAM. Back-up power can be supplied by a coin cell or the like. STANDBY mode is generally used while the primary battery is being replaced or recharged.
• In ALERT mode, the real time clock produces a signal at programmed, periodic intervals to activate all on-board electronic components. ALERT-ACTIVE submode has all circuits active. Exercises are generally performed during the ALERT-ACTIVE mode. In ALERT-SLEEP submode, only the real time clock and SRAM memory remain active. ALERT-SLEEP mode is the standard mode of operation between exercise prompts. To allow switching between submodes, primary and backup battery power should be available during the ALERT mode. A beeper function can be used to prompt the patient that an exercise time has been reached.
• FULL-ON mode primarily is used during programming and data transfer operations. All on-board electronics and the display are active. FULL-ON mode can be activated automatically when an interface cable is connected.
• In a preferred embodiment, the controller can prompt and monitor the performance of isometric exercises, range of motion exercises, isotonic exercises and/or neurosensory, reflex, proprioception and neuromotor exercises. When the patient has suffered a stroke, preferably the exercises involve more than simple proprioception. The stroke generally destroys neurological pathways involving brain cells controlling reflexes, movements, and the like. Thus, the patient must relearn new neurological pathways connected to different memory locations. A variety of reflex exercises can be used to relearn these neurological pathways.
• When the health care professional programs the controller, the desired exercises from this group of possible exercises are selected along with the associated parameters and timing conditions for the selected exercises. Also, the controller preferably can store two or more sets of exercise routine parameters that can be used in different time intervals relative to the start of rehabilitation. In other words, after a first set of exercise routines have been used for a certain period of time, the controller selects a second, generally more difficult, set of exercises for the patient to perform. These exercises can be performed for any selected joint or group of joints.
• Similarly, the control unit can be programmed to prompt the patient to perform different exercises at different time of the day. These can be designed in a variety of ways by the health care professional based on the particular circumstances of the patient. For example, the control unit can prompt the patent to perform range-of-motion exercises every three hours, finger squeeze exercises every hour and longer exercise sessions for neurological rehabilitation every evening.
• Preferably, the controller prompts the patient at the time for performance of the selected exercises. In some embodiments, the patient presses a key when they are ready to proceed. The display on the monitor can graphically show the patient's motions with suitable coordinates for the particular exercise and compare them with a target performance, if suitable. The controller can store all of the data points or averages over a set of exercises performed over a period of time.
• To perform the isometric exercises of a particular joint, the corresponding hinge is adjusted to a particular angle. If a manual hinge is used, the hinge is manually adjusted. The controller may instruct the patient if the hinge is set at the desired angle. At the correct angle, the patient applies stress against the fixed hinge in one direction or the other. The controller instructs the patient if the applied stresses are within tolerance values of a target value. The controller preferably prompts the patient regarding the timing of the exercises, including the repetition rate and the amount of time to hold an applied stress. After the selected number of repetitions are performed the exercises are terminated or a new angle of the hinge is selected. The process is repeated until exercises are performed at all of the desired angles for the particular joint. For hinges that rotate in multiple planes, the joint can be exercised with forces applied along any plane of motion appropriate for the joint. The motion can be in a single plane at a particular time or within multiple planes simultaneously, such as moving a hand in a circle with an outstretched arm.
• Improvement in joint function can be advanced with attention to achieving a desirable range-of-motion (ROM). The ROM can be monitored using the orthosis with a suitable position sensing hinge or hinges, as described above. The particular hinge is set to allow rotation, at least over a portion of the possible rotation range. For hinges that rotate in multiple planes of motion, the range-of-motion exercises can be performed in the different planes.
• Proprioception in this context refers to the patient's sense of position in space, such as the bend of a particular joint. This seeming innate knowledge is a learned phenomenon involving a complex interaction of nerve sensations from sensors that are processed and combined with feedback and correction. A joint has dozens of single-celled measurement sensors: Paninian-like receptors, Ruffini corpuscles and the like. The brain and spinal cord process the information from these cellular sensors. When a joint is damaged, dozens of sensors may be permanently lost. For example, the anterior cruciate ligament of a knee has over 60 sensor/receptor cells some of which may be lost when the ligament tears. The body makes up for lost receptors by recruiting new sensor information from adjacent places. A new pathway and analysis must be relearned by the nervous system. With a properly designed orthosis this process should be accelerated and enhanced.
• In one embodiment, the controller display prompts an action through a graphic display, for example, to get a ball back into a circle, and the patient must react quickly, reflexively with the rehabilitating joint in the orthosis to move the ball on the screen. The position of the ball on the screen is correlated with the position of the joint by way of the position sensor in the orthosis operably connected to the controller. By changing the position of the joint, e.g. knee, the patient can move the ball back into the circle or to another target of some kind. These exercises improve cooperation and coordination. A similar game format can be used to perform isometric exercises where the amount of strain measured by the strain gauge is used to move the cursor. For hinges/joints that rotate in multiple planes, the full range of motion can be explored in a proprioception exercise.
• Isotonic exercises are similar to the range-of-motion exercises except that selected resistance is provided in the selected hinge. Resistance is provided by a manual unit, such asresistance unit400 above, or by an electrical resistance hinge actuated by a controller, such aselectromechanical hinge240 above. In any case, a desired amount of resistance is set manually or automatically. The joint is then flexed over a prescribed range-of-motion. A controller can monitor the degree of flexing of the joint using a position sensor in the hinge and the amount of forces applied during the flexing using a strain gauge. The strain gauge can be calibrated such that a strain reading can be matched with a corresponding torque applied to the hinge.
• Some preferred embodiments include an additional component to provide for closed chain exercises when used with the joint supporting component. Closed chain exercises involve muscular motion against resistance to mimic natural motions against gravity or to provide balanced stresses to the joint. Closed chain exercises can be contrasted with open chain exercises where a limb or trunk is moved or stressed in space without any resistance against the motion other than perhaps the weight of the limb itself. Closed chain exercise may provide more balanced exercise of the various muscle groups within a patient's limb or trunk. The closed chain component may or may not be physically connected with the joint supporting orthosis components.
• For the performance of closed chain exercises, a body portion pushes against an essentially immovable surface. The surface can be a floor, a wall, a table top or the like. In order to monitor the forces being applied, a sensor is used that is placed between the body part and the surface, for example, thestress sensor898 ofheel support890. If closed chain exercises are to be performed with joints other than the knee, a suitable force sensor can be used. For example, a elbow can be exercised pushing with a hand against a pad sensor on a table or against a wall. These sensors can be connected to the controller. Additional information on the performance of the exercises described above and the corresponding programming of the controller is found in the 60/098,779 application.
• As noted above, the controller can be attached to a variety of additional devices, such as closed chain exercise units, energy propagating transducers and the like, to assist with treatment. Generally, the monitoring of the operation of these additional units can be performed with the controller in a straightforward manner.
• The controller can be programmed to accept other input from the patient. In particular, inquiries can be directed to the patient at the start of an exercise routine, at the end of an exercise routine or at other times. The answers are stored for downloading to a health care professional along with suitable information regarding the performance of programmed exercises.
• As part of the monitoring operation, the controller preferably, continuously monitors the performance of an exercise to prevent difficulties. For example, after exercises have been started, the transducer parameters are evaluated to determine if the exercises are being performed within specified parameters. If the exercises are not being performed within tolerance values, a sound warning can be given. Additional description on the performance of exercises with an instrumented orthosis are described in the 60/098,779 application.
• Periodically, the information stored by the processor is downloaded to a health care professional. Various methods for downloading the information were described above. In principle, the controller can store all of the information about the performance of particular sets of exercise routines and download all of this information for analysis. Alternatively, the controller can perform some initial data analysis to reduce the amount of data that must be stored and transferred. The preliminary analysis, if any, performed by the controller can include grouping and/or averaging of groups of exercises over certain periods of time and/or performed at particular times of the day. Thus, raw or analyzed data can be transferred. This analysis can involve an evaluation of variation with the progress of time to assist the health care professional evaluate whether the patient is making sufficient improvement and to evaluate whether the exercise routine programmed into the controller is appropriate.
• To reduce the chance of the patient injuring themselves using the orthoses described herein, the patient preferably is examined by a trained health care professional prior to using the orthosis. Upon evaluating the condition of the patient, the controller is programmed for suitable exercises. In preferred embodiments, a monitor station assists the health care professional with the programming process. Once the controller is connected to the monitor station by way of an RS 232 connection, a modem connection, a radio connection, a IR connection or other suitable connection using an appropriate protocol the program is downloaded into the controller.
• At prescribed periods of time, information stored in the controller regarding the performance of the exercises by the patient can be downloaded into the monitor station. The time interval can be determined based on the storage capacity of the controller, the suitable length for evaluation of progress by health care professional or other similar issues. The download of information from the controller to the monitor station can be performed at the health care facility where the monitor station is located or from a remote location. If performed at the health care facility, the information can be downloaded by direct hook up of the controller with the monitor station or through a modem, radio connection, infrared connection or the like. Remote hook up can be performed with a modem connection, internet connection, radio communication or other longer range connection. A combination of the downloading of performance parameters with telecommunications capability is described further in copending and commonly assigned U.S. patent application Ser. No. 09/226,866, entitled “REMOTE MONITORING OF AN INSTRUMENTED ORTHOSIS,” incorporated herein by reference.
• Suitable analysis is performed of the data for example, the downloaded data on the exercises can be plotted in raw form or following some form of data averaging or selection. Based on an evaluation of the downloaded data, the health care professional can maintain the exercise program in its initially programmed form or modify the exercise program to account for unexpected developments. In preferred embodiments, the health care professional can reprogram the controller remotely such that any desired changes in the routine can be made without the patient needing to visit the health care facility. Further information on performance data analysis is found in the 60/098,779 application.
• One of several important functions of a microprocessor controlled orthosis is to monitor compliance with performance of exercises. A useful adjunct to the compliance monitoring function can be achieved by performing a psychological evaluation of the patient. The psychological test can be used to evaluate the suitability of the programmed exercises as well as indicate other potential problems with the healing process not directly linked to the exercises.
• Specifically, patients undergoing treatment for an injury are under stress. Pain, immobility, lack of understanding, fear contribute to the stress resulting from the injury. The stress complicates recovery because the stress interacts with other emotional or physical complaints. In particular, patients under stress undergo changes in their psychology. This psychological change commonly manifests itself as depression, fear, anxiety, anger or other types of decompensation.
• The stress and associated changes in psychology complicates the recovery by impairing the patient's ability to understand the problem and to cooperate filly in their own recovery. For example, depressed patients experience more pain, as measured by increased need for pain medication. Also, depressed patients exert less force during physical testing and, therefore, are measurably weaker. Thus, stress and associated complications can result in an objective, measurable decrease in physical ability.
• In the past, such factors generally have been accommodated or accepted as unavoidable because there has been no way to follow easily or to evaluate reasonably the changes in the patient's mental state. The ability to monitor the patient's mental emotional state can lead to important advances in the treatment of orthopedic injuries. To make effective use of the information on the patient's emotional state, the information preferably is coordinated with other aspects of the orthopedic and neurological recovery.
• As a result of their injury, patients likely will undergo a predictable series of changes as they first adapt to the pain of their injury, the inconvenience, the expense and the change in their function. The patient's emotional changes likely will include aspects of denial anger, bargaining, acceptance, etc., which have also been associated with death and dying, as described by Elisabeth Kübler-Ross. For a more complete description of these emotional changes see “On Death and Dying,” Elisabeth Kübler-Ross, Simon & Schuster (1969), incorporated herein by reference. These changes can be correlated with predictable or identifiable factors, such as age, gender, mechanism and socio-economic status.
• The emotional changes are a form of psychological pain. Since it is known that patients will undergo these emotional changes, a more complete treatment of the patient includes the management of the emotional changes accompanying the physical trauma. Effective management and/or treatment of the emotional changes preferably would involve 1) education, 2) monitoring, 3) accurate characterization, 4) cooperation-based contingent intervention, and 5) communication.
• In analogy with Kübler-Ross models, patients can benefit from the simple knowledge that emotional changes are common and predictable. Reassuring information can be passed along to the patient at regular intervals, consistent with identifiable patient demographic parameters. Patient suffering is reduced by mental preparation. The educational data can only be presented with optimum timing if the patient's ability to absorb the information is known. Thus, individual specific and time specific psychological quantification can be used to considerable advantage. Psychological quantification can be accomplished efficiently through portable psychological testing coordinated with the patient's physical therapy or exercise prescription. In particular, appropriate educational information can be presented by the controller.
• As part of the monitoring function, the treating professional preferably knows what the patient is experiencing and when they are experiencing it. These experiences will be based on the patient's specific stresses, demands, events and individual psychology. The experiences also will parallel progress or relapse in the orthopedic treatment regime. While qualitative features of the patient's emotional responses may be predictable, it is difficult to know when the psychological treatment can be effectively provided. By analogy, with physical discomfort the specific timing of effective administration of pain medication, assistance with physical activities and nursing assistance is highly variable and patient specific. The treatment is more effective when the patient is able to say when they require pain medication or other forms of help.
• Monitoring is an important component to effective treatment. Effective monitoring is not possible without ongoing, systematic and injury appropriate querying of the patient. To perform this in a cost effective way, the monitoring function must be portable with the patient. This portable monitoring can be accomplished by incorporating psychological monitoring on an orthopedic management system, such as those described herein. In particular, the monitoring function can be coordinated by the controller, which is programmed to pose questions and to receive answers from the patient. The psychological monitoring can be used to modify parameters in the orthopedic management, such as device comfort, exertion levels and pain control, when the monitoring function detects deviations from an expected emotional or psychological condition.
• To obtain an accurate characterization of the patient's emotional state, the treating professional and the patient need to work together to determine the stage of the patient's emotional recovery, the depth and type of the patient's distress, and changes in the patient's emotional condition as the problem either resolves or worsens. There are a number of literature based instruments available that have been used to characterize patients on a one-time basis to quantify an emotional state. These instruments can be adapted to an ongoing monitoring of a constantly evolving medical-surgical state, such as associated with an orthopedic or neurological injury.
• A first instrument for emotional evaluation involves the formation of a pain diagram. The patient is asked if the pain occurs at the expected location. Pain away from the expected location may indicate a complication or missed injury. See the discussion in Mayer et al., “A Prospective Short-Term Study of Chronic Low Back Pain Patients Utilizing Novel Objective Functional Measurement, Pain 25:53-68 (1986), incorporated herein by reference.
• An alternative approach is known as the Million analog scale. The patient is asked to characterize their discomfort based on a range of possible limitations. For example, they may be asked to state on an arbitrary scale their perceived functional restriction from “no pain” to “worst possible pain.” In addition, they may be asked whether they are easily able to work, unable to work or some gradation between these limits. The responses generally change based on the patient's recovery process and their perception of their recovery process. Thus, this is a straightforward tool to regularly administer during high risk periods as a significant tool to report changes in the patient's condition. For further discussion of this approach see, for example, R. Million et al., “Assessment of the Progress of the Back-Pain Patient,” Spine, 7(3):204-212 (1982), incorporated herein by reference.
• Patient's often find it difficult to describe their symptoms. In addition, patients in a certain high risk category for back injury are likely to have a range of educational limitations. This is a paradox that the patients who are most likely to sustain a certain type of injury are also least likely to be able to adequately characterize it as needing and deserving treatment. The McGill Pain Questionnaire provides a tool to overcome these difficulties. The McGill Pain Questionnaire uses words that the patient can understand and appropriately choose, but words that the patient would not likely use without suggestion. The words are provided in a format and grouping that tells more about the patient's situation and emotional state than just their pain level. A further description of the McGill Pain Questionnaire is described in R. Melzack, “The McGill Pain Questionnaire: Major Properties and Scoring Methods,” Pain 1:277-299 (1975), incorporated herein by reference. The questionnaire can be updated and modified as appropriate.
• Another potential instrument is the Beck Depression Inventory (BDI). Depression often follows injury and states of pain. A method of polling the patient for signs of depression would be another usefull method of controlling and improving the recovery process, as the patient progresses through their disease process.
• The BDI is a series of questions whose answers reflect the patient's mental state with respect to indications of depression. The BDI provides a standardized, objective measure that approximates clinical judgments of the intensity of depression without variability due to an evaluator's idiosyncrasies or theoretical orientation. The BDI's ease of administration and low cost provide for its economical use, for example, with a patient suffering from an orthopedic injury. Furthermore, statistical analysis can be performed with the quantitative data generated by the BDI.
• In its standard form, the BDI consists of 21 items that are scored to assess the patient's state of depression. Each of the 21 items can be rated on a scale of 0-3 such that the total score ranges from 0-63. The patient selects the number next to a statement that reflects the way that he/she has felt over a selected time period. The degree of depression is evaluated by the sum of the individual numbers with totals indicating as follows: 0-9 no depression, 10-16 mild depression, 17-29 moderate depression and 30-63 severe depression. In the standard test, the 21 items are: 1) sadness, 2) pessimism, 3) failure, 4) dissatisfaction, 5) guilt, 6) punishment, 7) self-dislike, 8) self-accusations, 9) suicidal thought, 10) crying, 11) irritability, 12) withdrawal, 13) indecision, 14) self-image, 15) work inhibition, 16) insomnia, 17) fatigue, 18) anorexia, 19) weight loss, 20) hypochondria, 21) libido loss.
• In summary, these instruments can be used 1) to demonstrate the location of pain as typical or atypical (the pain diagram), 2) to evaluate the patient's own perceived level of disability (the million analog scale), 3) to describe the specific nature of the pain as stinging, burning, torturing, or the like (the McGill Pain Questionnaire), or to reflect the effect of the difficulties on the patient's mental state (Beck Depression Inventory). Suitable tests are described further in the 60/098,779 application. Thus, standardized instruments for emotional evaluation can be integrated into an orthopedic treatments regime organized around an instrumented orthosis.
• In particular, the questions can be posed and the answers received through the controller. These questions can be posed at regular intervals. The questions can be interspersed throughout the day and coordinated with the timing of exercise routines. In particular, different subset of questions can be asked at different times. For example, a subset of questions on pain levels can be asked in the morning while a subset of questions on depression can be asked in the afternoon. To assist with these tests, the controller can be attached to a television set to provide a larger display, if desired. If administered in an appropriate and timely manner, the subjective aspects of the patient's suffering can be identified and quantified for appropriate intervention.
• The psychological test can be integrated with the physical evaluation of the patient to form a more complete overall evaluation. Using this evaluation, the exercise routine can be modified in response partly to the to mental attitude of the patient to help assure further compliance with the exercises and to increase the comfort level of the patient. The balance of all of these factors can lead to faster rehabilitation of the patient.
• The patient's ability to cooperate with their treatment is determined by their emotional state. Like physical pain, the patient's emotional state changes in a highly individualized manner. If the patient's emotional state can be more scientifically evaluated, characterized and bracketed with identifiable ranges and types, the modification to a more effective or more pleasurable reinforcement scheme can be assisted through cooperation-based contingent intervention. In particular, the information received from the patient is used to improve the cooperation of the patient in their own recovery. Thus, the relationship between the patient and the treating professional is augmented in a way that strengthens the relationship without adding unreasonable cost to treatment.
• With respect to implementing the cooperation-based contingent intervention, the controller first evaluates the immediacy of the patient's state. If there are serious concerns, such as if the patient indicates that the pain is unbearable or tortuous or if the patient is seriously depressed, the controller can either instruct the patient to immediately call the doctor or directly interface with the health professional's computer to down load the information, with the patient's help, if needed. Alternatively, the controller can modify the exercise level by decreasing the exertion if the pain is higher than desired or increase the level if the pain is low and the patient is frustrated by the slow pace.
• Thus, the patient's physical and mental condition, as communicated in the psychological evaluation, can provide useful information regarding the modifications to the treatment program in response to the patient's evolving physical condition and the mental state of the patient. Cooperation-based contingent intervention involves integrating the result of the psychological evaluation to the patient's evolving physical abilities to provide for improved adjustment of the treatment program. For example, a variety of different formats for presenting a particular exercise can be tried to evaluate whether the patient is more receptive to the particular formats. The formats can be put in the form of a game or in the form of detailed instructions with continuous positive reinforcement.
• Communication with the health care professional is an important aspect of the process. The controller can be used to intervene in the communication process to ensure that important information is communicated in a timely way. Regardless of any immediate concerns, the outcome of the patient's responses are reported to the treating professional for confirmation, data analysis and other types of support. Prior to evaluation by the health care professional, the patient's responses are characterized and identified. This can be done by the controller or by a remote processor. A scientific and quantifiable method of evaluating emotional change is an important component of the evaluation process.
• As a supplement to or as an alternative to, the questioning of the patient regarding their emotional state, physiological measurements can be made regarding conditions correlated with stress. For example, pulse rate can be measured with, for example, a laser Doppler sensor or a pulse oximeter. A pulse oximeter is an apparatus that the patient inserts their finger into to measure pulse rate and blood oxygenation. Similarly, galvanic skin response can be measured using electrodes placed on the skin. The electric resistance of skin is measured with the electrodes. In addition, blood pressure can be measured with a blood pressure cuff. These physiological measurements can be controlled and monitored with the controller. The physiological measurements can then be downloaded to the health care provider.
• The embodiments described above are intended to be illustrative and not limiting. Additional embodiments are within the claims. Although the present invention has been described with reference to preferred embodiments, workers skilled in the art will recognize that changes may be made in form and detail without departing from the spirit and scope of the invention.

Claims (40)

1. An ambulatory medical device comprising a display, an input device, a microprocessor, memory, a download channel with an output portal and software wherein the software executes on the microprocessor to present questions on the psychological state of the patient with answers being input through the input device for storage for subsequent downloading from the output portal.

2. The ambulatory medical device ofclaim 1 wherein the display comprises an LCD display.

3. The ambulatory medical device ofclaim 1 wherein the input device comprises a keypad.

4. The ambulatory medical device ofclaim 1 wherein the microprocessor has a deep sleep mode.

5. The ambulatory medical device ofclaim 1 wherein the microprocessor has analog to digital multiplexing capability.

6. The ambulatory medical device ofclaim 1 wherein the memory is non-volatile memory.

7. The ambulatory medical device ofclaim 1 wherein the output comprises an RS-232 port.

8. The ambulatory medical device ofclaim 1 wherein the output comprises an internal modem.

9. The ambulatory medical device ofclaim 1 wherein the output comprises a radio transmitter.

10. The ambulatory medical device ofclaim 1 wherein the questions relate to pain levels.

11. The ambulatory medical device ofclaim 1 wherein the questions relate to the formation of a pain diagram.

12. The ambulatory medical device ofclaim 1 wherein the questions relate to depression.

13. The ambulatory medical device ofclaim 12 wherein a statistical analysis is performed on the depression questions to obtain an objective quantitative measure of depression.

14. The ambulatory medical device ofclaim 1 wherein the device is further connected to an orthosis.

15. The ambulatory medical device ofclaim 1 wherein the device is further connected to a pulse rate sensor, galvanic skin response or a blood pressure sensor.

16. A method for remote evaluation of the psychological state of a patient, the method comprises posing questions to a patient using an ambulatory device comprising a display, an input device, a microprocessor, memory, an output portal and software wherein the software executes on the microprocessor to present questions on the psychological state of the patient with answers being input through the input device for storage for subsequent downloading from the output portal.

17. The method ofclaim 16 wherein the questions relate to pain levels.

18. The method ofclaim 16 wherein the questions relate to the formation of a pain diagram.

19. The method ofclaim 16 wherein the questions relate to depression.

20. The method ofclaim 19 wherein a statistical analysis is performed on the depression questions to obtain an objective quantitative measure of depression.

21. The method ofclaim 16 wherein the psychological evaluation is coupled with a physiological evaluation.

22. The method ofclaim 21 wherein the physiological evaluation comprises evaluation of the performance of target exercises.

23. The method ofclaim 21 wherein the physiological evaluation comprises pulse measurements.

24. The method ofclaim 21 wherein the physiological evaluation comprises blood pressure measurements.

25. The method ofclaim 21 wherein the physiological evaluation comprises galvanic skin response measurements.

26. The method ofclaim 16 further comprising modifying a treatment program in response to the psychological evaluation.

27. The method ofclaim 16 wherein the downloading of important information is performed in a timely way.

28. The method ofclaim 16 further comprising characterizing the patient's answers prior to review by a health care professional.

29. The method ofclaim 28 wherein the characterization is performed on the ambulatory medical device.

30. The method ofclaim 28 wherein the characterization is performed on a central processor.

31. The method ofclaim 16 wherein detection of specific responses from the patient prompts an instruction to the patient to immediately contact a treatment professional.

32. A method of evaluating a patient's mental condition comprising:

collecting answers to a set of questions regarding the patient's mental condition using a remote controller programmed to pose the questions and receive the answers; and

evaluation of the answers by a health care professional.

33. The method ofclaim 32 further comprising performing initial analysis of the answers using a computer processor.

34. The method ofclaim 32 wherein the remote controller is operably connected to transducers associated with an orthosis.

35. The method ofclaim 34 wherein the transducers are selected from the group consisting of strain gauges, position sensors, and combinations thereof.

36. The method ofclaim 34 wherein the orthosis comprises a hinge that can rotate in several different planes and a position sensor operably connected to the hinge such that motion can be measured with respect to different rotational motions around the joint, the controller being operably connected to the position sensor to receive signals related to the position of the hinge.

37. The method ofclaim 34 wherein the orthosis comprises a plurality of hinges such that motions about separate hinges correspond to motions about different joints.

38. The method ofclaim 32 wherein the controller further processes a signal related to a physiological condition in the patient correlated with stress.

39. The method ofclaim 38 wherein the physiological condition is pulse rate.

40. The method ofclaim 38 wherein the physiological condition is the galvanic skin response.

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