Assisting hand function after spinal cord injury with a fabric-based soft robotic glove.

BACKGROUND: Spinal cord injury is a devastating condition that can dramatically impact hand motor function. Passive and active assistive devices are becoming more commonly used to enhance lost hand strength and dexterity. Soft robotics is an emerging discipline that combines the classical principles of robotics with soft materials and could provide a new class of active assistive devices. Soft robotic assistive devices enable a human-robot interaction facilitated by compliant and light-weight structures. The scope of this work was to demonstrate that a fabric-based soft robotic glove can effectively assist participants affected by spinal cord injury in manipulating objects encountered in daily living. METHODS: The Toronto Rehabilitation Institute Hand Function Test was administered to 9 participants with C4-C7 spinal cord injuries to assess the functionality of the soft robotic glove. The test included object manipulation tasks commonly encountered during activities of daily living (ADL) and lift force measurements. The test was administered to each participant twice; once without the assistive glove to provide baseline data and once while wearing the assistive glove. The object manipulation subtests were evaluated using a linear mixed model, including interaction effects of variables such as time since injury. The lift force measures were separately evaluated using the Wilcoxon signed-rank test. RESULTS: The soft robotic glove improved object manipulation in ADL tasks. The difference in mean scores between baseline and assisted conditions was significant across all participants and for all manipulated objects. An improvement of 33.42 ± 15.43% relative to the maximal test score indicates that the glove sufficiently enhances hand function during ADL tasks. Moreover, lift force also increased when using the assistive soft robotic glove, further demonstrating the effectiveness of the device in assisting hand function. CONCLUSIONS: The results gathered in this study validate our fabric-based soft robotic glove as an effective device to assist hand function in individuals who have suffered upper limb paralysis following a spinal cord injury.

Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population.

OBJECTIVE: The Defense and Veterans Pain Rating Scale (DVPRS 2.0) is a pain assessment tool that utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain interferes with usual activity and sleep, and affects mood and contributes to stress. METHODS: Psychometric testing was performed on a revised DVPRS 2.0 using data from 307 active duty service members and Veterans experiencing acute or chronic pain. A new set of facial representations designating pain levels was tested. RESULTS: Results demonstrated acceptable internal consistency reliability (Cronbach's alpha = 0.871) and test-retest reliability (r = 0.637 to r = 0.774) for the five items. Excellent interrater agreement was established for correctly ordering faces depicting pain levels and aligning them on the pain intensity scale (Kendall's coefficient of concordance, W = 0.95 and 0.959, respectively). Construct validity was supported by an exploratory principal component factor analysis and known groups validity testing. Most participants, 70.9%, felt that the DVPRS was superior to other pain rating scales. CONSCLUSION: The DVPRS 2.0 is a reliable and valid instrument that provides standard language and metrics to communicate pain and related outcomes.

Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population.

BACKGROUND: The Army Surgeon General released the Pain Management Task Force final report in May 2010. Among military providers, concerns were raised that the standard numeric rating scale (NRS) for pain was inconsistently administered and of questionable clinical value. In response, the Defense and Veterans Pain Rating Scale (DVPRS) was developed. METHODS: The instrument design integrates pain rating scale features to improve interpretability of incremental pain intensity levels, and to improve communication and documentation across all transitions of care. A convenience sample of 350 inpatient and outpatient active duty or retired military service members participated in the study at Walter Reed Army Medical Center. Participants completed the five-item DVPRS-one pain intensity NRS with and without word descriptors presented in random order and four supplemental items measuring general activity, sleep, mood, and level of stress and the Brief Pain Inventory seven interference items. Using systematic sampling, a random sample was selected for a word descriptor validation procedure matching word phases to corresponding pain intensity on the NRS. RESULTS: Parallel forms reliability and concurrent validity testing demonstrated a robust correlation. When the DVPRS was presented with the word descriptors first, the correlation between the two ratings was slightly higher, r = 0.929 (N = 171; P < 0.001), than ordering first without the descriptors, r = 0.882 (N = 177; P < 0.001). Intraclass correlation coefficient was 0.943 showing excellent alignment of word descriptors by respondents (N = 42), matching them correctly with pain level. CONCLUSIONS: The DVPRS tool demonstrated acceptable psychometric properties in a military population.

Modal-Based Kinematics and Contact Detection of Soft Robots.

Soft robots offer an alternative approach to manipulate within a constrained space while maintaining a safe interaction with the external environment. Owing to its adaptable compliance characteristic, external contact force can easily deform the robot shapes and lead to undesired robot kinematic and dynamic properties. Accurate contact detection and contact location estimation are of critical importance for soft robot modeling, control, trajectory planning, and eventually affect the success of task completion. In this article, we focus on the investigation of a one degree of freedom (1-DoF) soft pneumatic bending robot, which is regarded as one of the fundamental components to construct complex, multi-DoFs soft robots. This 1-DoF soft robot is modeled through the integral representation of the spatial curve, where direct and instantaneous kinematics are calculated explicitly through a modal method. The fixed centrode deviation method is used to detect the external contact and estimate the contact location. Simulation results and experimental studies indicate that the contact location can be accurately estimated by solving a nonlinear least-square optimization problem. Experimental validation shows that the proposed algorithm is able to successfully estimate the contact location with the estimation error of 1.46 mm.

Extension for Community Healthcare Outcomes (ECHO) Telementoring in the Military: Where We Are Now, Opportunities and Challenges.

INTRODUCTION: In collaboration with the ECHO (Extension for Community Healthcare Outcomes) Institute since 2012, the Army, Navy, and Air Force have developed medical teleECHO programs to address various health and safety issues affecting military personnel. This article describes and compares the current state of military teleECHOs as well as the growth and change over time. MATERIALS AND METHODS: This study evaluated continuing education units (CEUs) offered, average session attendance, and number of spoke sites for current military teleECHO programs across the service branches. RESULTS: Between 2012 and 2019, the military teleECHO initiative grew from one program to seven different teleECHO programs, covering topics from pain to diabetes to amputee care. Military ECHOs now provide training to 10 countries and 27 states in the United States. Between October 2018 and September 2019, the military ECHO programs provided a total of 51,769 continuing medical education (CME) hours to a total of 3,575 attendees from 223 spoke sites. CONCLUSIONS: The military has successfully used the ECHO model to improve the health and safety of active-duty military, retirees, and dependents.

Beacon-referenced pursuit for collective motions in three dimensions.

Motivated by real-world applications of unmanned aerial vehicles, this paper introduces a decentralized control mechanism to guide steering control of autonomous agents manoeuvring in the vicinity of multiple moving entities (e.g. other autonomous agents) and stationary entities (e.g. fixed beacons or points of reference) in a three-dimensional environment. The proposed control law, which can be perceived as a modification of the three-dimensional constant bearing (CB) pursuit law, provides a means to allocate simultaneous attention to multiple entities. We investigate the behaviour of the closed-loop dynamics for a system with one agent referencing two beacons, as well as a two-agent mutual pursuit system wherein each agent employs the beacon-referenced CB pursuit law with regards to the other agent and a stationary beacon. Under certain assumptions on the associated control parameters, we demonstrate that this problem admits circling equilibria with agents moving on circular orbits with a common radius, in planes perpendicular to a common axis passing through the beacons. As the common radius and distances from the beacon are determined by the choice of parameters in the pursuit law, this approach provides a means to engineer desired formations in a three-dimensional setting.

Fiber Optic Shape Sensing for Soft Robotics.

While soft material actuators can undergo large deformations to execute very complex motions, what is critically lacking in soft material robotic systems is the ability to collect high-resolution shape information for sophisticated functions such as environmental mapping, collision detection, and full state feedback control. This work explores the potential of a nearly commercial fiber optic shape sensor (FOSS) and presents the first demonstrations of a monolithic, multicore FOSS integrated into the structure of a fiber-reinforced soft actuator. In this pilot study, we report an open loop sensorized soft actuator capable of submillimeter position feedback that can detect the soft actuator's shape, environmental shapes, collision locations, and material stiffness properties.

Exploiting Textile Mechanical Anisotropy for Fabric-Based Pneumatic Actuators.

Knit, woven, and nonwoven fabrics offer a diverse range of stretch and strain limiting mechanical properties that can be leveraged to produce tailored, whole-body deformation mechanics of soft robotic systems. This work presents new insights and methods for combining heterogeneous fabric material layers to create soft fabric-based actuators. This work demonstrates that a range of multi-degree-of-freedom motions can be generated by varying fabrics and their layered arrangements when a thin airtight bladder is inserted between them and inflated. Specifically, we present bending and straightening fabric-based actuators that are simple to manufacture, lightweight, require low operating pressures, display a high torque-to-weight ratio, and occupy a low volume in their unpressurized state. Their utility is demonstrated through their integration into a glove that actively assists hand opening and closing.

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

Introduction: Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods: ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results: Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion: The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

A Modular Soft Robotic Wrist for Underwater Manipulation.

This article presents the development of modular soft robotic wrist joint mechanisms for delicate and precise manipulation in the harsh deep-sea environment. The wrist consists of a rotary module and bending module, which can be combined with other actuators as part of a complete manipulator system. These mechanisms are part of a suite of soft robotic actuators being developed for deep-sea manipulation via submersibles and remotely operated vehicles, and are designed to be powered hydraulically with seawater. The wrist joint mechanisms can also be activated with pneumatic pressure for terrestrial-based applications, such as automated assembly and robotic locomotion. Here we report the development and characterization of a suite of rotary and bending modules by varying fiber number and silicone hardness. Performance of the complete soft robotic wrist is demonstrated in normal atmospheric conditions using both pneumatic and hydraulic pressures for actuation and under high ambient hydrostatic pressures equivalent to those found at least 2300 m deep in the ocean. This rugged modular wrist holds the potential to be utilized at full ocean depths (>10,000 m) and is a step forward in the development of jointed underwater soft robotic arms.

A Dexterous, Glove-Based Teleoperable Low-Power Soft Robotic Arm for Delicate Deep-Sea Biological Exploration.

Modern marine biologists seeking to study or interact with deep-sea organisms are confronted with few options beyond industrial robotic arms, claws, and suction samplers. This limits biological interactions to a subset of "rugged" and mostly immotile fauna. As the deep sea is one of the most biologically diverse and least studied ecosystems on the planet, there is much room for innovation in facilitating delicate interactions with a multitude of organisms. The biodiversity and physiology of shallow marine systems, such as coral reefs, are common study targets due to the easier nature of access; SCUBA diving allows for in situ delicate human interactions. Beyond the range of technical SCUBA (~150 m), the ability to achieve the same level of human dexterity using robotic systems becomes critically important. The deep ocean is navigated primarily by manned submersibles or remotely operated vehicles, which currently offer few options for delicate manipulation. Here we present results in developing a soft robotic manipulator for deep-sea biological sampling. This low-power glove-controlled soft robot was designed with the future marine biologist in mind, where science can be conducted at a comparable or better means than via a human diver and at depths well beyond the limits of SCUBA. The technology relies on compliant materials that are matched with the soft and fragile nature of marine organisms, and uses seawater as the working fluid. Actuators are driven by a custom proportional-control hydraulic engine that requires less than 50 W of electrical power, making it suitable for battery-powered operation. A wearable glove master allows for intuitive control of the arm. The manipulator system has been successfully operated in depths exceeding 2300 m (3500 psi) and has been field-tested onboard a manned submersible and unmanned remotely operated vehicles. The design, development, testing, and field trials of the soft manipulator is placed in context with existing systems and we offer suggestions for future work based on these findings.

Use of the Pain Assessment Screening Tool and Outcomes Registry in an Army Interdisciplinary Pain Management Center, Lessons Learned and Future Implications of a 10-Month Beta Test.

INTRODUCTION: The U.S. Army Comprehensive Pain Management Campaign Plan was launched in 2010 to improve pain outcomes in military populations. Interdisciplinary Pain Management Centers (IPMCs) were established at every Army medical center, each offering a robust array of treatment options including conventional and complementary and integrative medicine (CIM) pain management therapies. The Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was developed to assess and track biopsychosocial aspects of pain management and to identify best treatment practices. METHODS: During a 10-month pilot test of PASTOR at one Army IPMC, active duty patients completed PASTOR at baseline and at significant junctures during their therapeutic course. RESULTS: 322 IPMC patients completed baseline and follow-up PASTOR assessments. The PASTOR outcomes were analyzed for patients who completed a 3- to 6-week CIM program, a 3-week functional restoration program, or both. For most PASTOR domains, a greater proportion of patients who completed both programs reported important improvement compared with patients who completed either program alone. CONCLUSIONS: This pilot test demonstrated the utility of using PASTOR in a military IPMC to track biopsychosocial treatment outcomes. These preliminary data will inform future comparative effectiveness analyses of pain therapies among military and veteran populations.

Symmetry and reduction in collectives: low-dimensional cyclic pursuit.

We investigate low-dimensional examples of cyclic pursuit in a collective, wherein each agent employs a constant bearing (CB) steering law relative to exactly one other agent. For the case of three agents in the plane, we characterize relative equilibria and pure shape equilibria of associated closed-loop dynamics. Re-scaling time yields a reduction of phase space to two dimensions and effective tools for stability analysis. Study of bifurcation of a family of collinear equilibria dependent on a single CB control parameter reveals the presence of a rich collection of trajectories that are periodic in shape and undergo precession in physical space. For collectives in three dimensions, with an appropriate notion of CB pursuit strategy and corresponding steering law, the two-agent case proves to be explicitly integrable. These results suggest control schemes for small teams of mobile robotic agents engaged in area coverage tasks such as search and rescue, and raise interesting possibilities for behaviour in biological contexts.

Pain as a Barrier to Human Performance: A Focus on Function for Self-Reporting Pain With the Defense Veterans Pain Rating Scale.

The intense physical demands and dangerous operational environments common to Special Operations Forces (SOF) result in a variety of painful conditions, including musculoskeletal pain, headaches, and acute and chronic pain from combat injuries. Pain is a wellaccepted barrier to human performance. The Pain Management Task Force and the development of the Defense Veterans Pain Rating Scale (DVPRS) are discussed to provide a framework for changing the culture of pain management away from intensity of pain to interference with function and performance. The emergence of complementary and integrative pain management (CIM) practices is briefly reviewed as viable alternatives to the traditional reliance on opioids and other prescription medications. The SOF community can be the change agent for the DVPRS and CIM approaches to pain management, which will in the end serve to accelerate recovery and return SOF operators to duty faster and with an enhanced ability to perform with less pain.

Soft Robotic Grippers for Biological Sampling on Deep Reefs.

This article presents the development of an underwater gripper that utilizes soft robotics technology to delicately manipulate and sample fragile species on the deep reef. Existing solutions for deep sea robotic manipulation have historically been driven by the oil industry, resulting in destructive interactions with undersea life. Soft material robotics relies on compliant materials that are inherently impedance matched to natural environments and to soft or fragile organisms. We demonstrate design principles for soft robot end effectors, bench-top characterization of their grasping performance, and conclude by describing in situ testing at mesophotic depths. The result is the first use of soft robotics in the deep sea for the nondestructive sampling of benthic fauna.

Expanding Health Care Access Through Education: Dissemination and Implementation of the ECHO Model.

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based model that provides high-quality medical education for common and complex diseases through telementoring and comanagement of patients with primary care clinicians. In a one to many knowledge network, the ECHO model helps to bridge the gap between primary care clinicians and specialists by enhancing the knowledge, skills, confidence, and practice of primary care clinicians in their local communities. As a result, patients in rural and urban underserved areas are able to receive best practice care without long waits or having to travel long distances. The ECHO model has been replicated in 43 university hubs in the United States and five other countries. A new replication tool was developed by the Project ECHO Pain team and U.S. Army Medical Command to ensure a high-fidelity replication of the model. The adoption of the tool led to successful replication of ECHO in the Army Pain initiative. This replication tool has the potential to improve the fidelity of ECHO replication efforts around the world.

First controlled vertical flight of a biologically inspired microrobot.

In this paper, we present experimental results on altitude control of a flying microrobot. The problem is approached in two stages. In the first stage, system identification of two relevant subsystems composing the microrobot is performed, using a static flapping experimental setup. In the second stage, the information gathered through the static flapping experiments is employed to design the controller used in vertical flight. The design of the proposed controller relies on the idea of treating an exciting signal as a subsystem of the microrobot. The methods and results presented here are a key step toward achieving total autonomy of bio-inspired flying microrobots.