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Possible use of robotic massage complexes in the medical rehabilitation programs for the patients with injuries and musculoskeletal disorders
“Is it possible to take advantage of mechanical advances for the construction of such machines that would replace the hand manipulations? It would be worthwhile to invent a machine, the strength of which could be determined at every moment in numbers and instead of the masseur’s work, one could deal with the work expressed in numbers. In other words, instead of taking the balm by eye, weigh it on the precision balances”
I.Z. Zabludovsky, 1882
At present, the development and application of medical robotic technologies, medical robotic devices, automated technical systems in healthcare is quite successful and has great potential for further advancements [1; 6]. There are several reasons for such a rapid introduction of innovative technologies into the medical practice, and it is not only obsession with inventive powers, but also the personal ability to find the non-standard solutions to the problems and life tasks that has the purely biological grounds.
Every year the Earth population is growing faster than the number of highly qualified specialists. The particularly pressing problem is the nursing shortage. They are the specialists who perform the complicated but routine tasks directly “at the patient’s bedside”, especially as a part of comprehensive medical rehabilitation programs. Over time, this trend will undoubtedly lead to the fact that the experienced specialists will focus on those skills that, for one reason or another, cannot be automated, and all other functions will be performed by the robotic complexes with the artificial intelligence feature.
In addition, during any medical procedure, it is quite difficult to accurately control the procedural protocol, and even more so to protect confidentiality of the patient and the comfort zone optimal for him/her. It is related to the so-called human factor.
These reasons and a number of other reasons force the healthcare providers to think about automation of individual medical staff activities using the robotic systems.
It is expected that the use of medical robots has clear advantages providing the following:
Along with robotic prostheses and exoskeletons (ReWalk, ExoAtlet), humanoids (SimMan 3G, Simroid), service robot assistants (Helpmate, RP-8, RIBA), robotic rehabilitation systems (Biodex, Lokomat, Con-trex, ReoGo, G-EO, С-MiLL, Erigo, Armeo), as well as robotic manipulators for surgery, especially microsurgery (da Vinci, Smart Tissue), an important and promising area emphasized by the experts in the field of medical robotics includes the robotic units for medical procedures in the patients with the musculoskeletal disorders, in particular the manipulation robots for massage and passive movements [2].
For the first time, the idea of the massage hardware robotic control was proposed by the scientists at the 2nd Symposium on Medical Robotics in Heidelberg in 1997. The Puma 560 six-unit industrial robot, designed for assembly and arc welding, was supplemented with a force sensor to measure the interaction force of the robot tool with the patient's soft tissues. The robot "felt" the patient, memorized its body contours, elasticity, then calculated the massage trajectories and reproduced them using its drives. The standard robot control system, designed for the positional and continuous-path control, could respectively implement the algorithms for separate position-force control. The robot used individual classical massage methods and acupressure techniques for the dummies, dogs, and human volunteers. This robotic massage method was protected by a patent [3].
Subsequently, the developed domestic robotic manipulation complex was improved under the auspices of the State Industrial University and the National Medical Research Center for Rehabilitation and Balneology of the Ministry of Healthcare of [4]. The robotic arm software was developed on the basis of the OMRON TM5-700 collaborative robot (Japan). Moreover, a diagnostic strain-algorithmometric unit, an equipment assembly designed to make a three-dimensional model of the human body surface and a temperature scanning system (temperature mapping of the patient's body surface) were added.
Later, the similar manipulative robots were developed at the Massachusetts Institute of Technology, Beijing University, Kin Teck Tong Singapore Medical Center, where the devices were clinically tested on the patients with traumatic epicondylitis, back pain and neck stiffness, as well as other pathological conditions [7; 8; 9; 10].
However, when implementing the proposed robotic systems, the following organizational and technical problems still remain unresolved:
In an attempt to solve at least some of these problems, if not all of them, in 2021 Beautyliner Group, proposed the Robosculptor robotic massage complex (Fig. 1) for practical use that was based on a collaborative robotic arm equipped with a massage nozzle, a high-speed time-of-flight (FoT) camera for making the patient 3D images, an infrared camera for solving the patient’s body recognition problems, a platform for the robotic arm movement along the human body, as well as an adjustable couch, a supporting unit frame and other auxiliary systems.
Every year the Earth population is growing faster than the number of highly qualified specialists. The particularly pressing problem is the nursing shortage. They are the specialists who perform the complicated but routine tasks directly “at the patient’s bedside”, especially as a part of comprehensive medical rehabilitation programs. Over time, this trend will undoubtedly lead to the fact that the experienced specialists will focus on those skills that, for one reason or another, cannot be automated, and all other functions will be performed by the robotic complexes with the artificial intelligence feature.
In addition, during any medical procedure, it is quite difficult to accurately control the procedural protocol, and even more so to protect confidentiality of the patient and the comfort zone optimal for him/her. It is related to the so-called human factor.
These reasons and a number of other reasons force the healthcare providers to think about automation of individual medical staff activities using the robotic systems.
It is expected that the use of medical robots has clear advantages providing the following:
- replacement of the time-consuming manual work of medical professionals;
- reduction in the medical staff number involved in the treatment process;
- realization of the possibility of virtually unlimited throughput of robotic complexes;
- usage of the precise motor tasks that are difficult to perform without special equipment;
- reduction of the recovery time of impaired functions due to the long-term stereotypical training of cyclic locomotor behavior;
- performance of procedures with the treatment and diagnostic interaction, using biofeedback that allows each time to select the most optimal operating mode for each individual patient.
Along with robotic prostheses and exoskeletons (ReWalk, ExoAtlet), humanoids (SimMan 3G, Simroid), service robot assistants (Helpmate, RP-8, RIBA), robotic rehabilitation systems (Biodex, Lokomat, Con-trex, ReoGo, G-EO, С-MiLL, Erigo, Armeo), as well as robotic manipulators for surgery, especially microsurgery (da Vinci, Smart Tissue), an important and promising area emphasized by the experts in the field of medical robotics includes the robotic units for medical procedures in the patients with the musculoskeletal disorders, in particular the manipulation robots for massage and passive movements [2].
For the first time, the idea of the massage hardware robotic control was proposed by the scientists at the 2nd Symposium on Medical Robotics in Heidelberg in 1997. The Puma 560 six-unit industrial robot, designed for assembly and arc welding, was supplemented with a force sensor to measure the interaction force of the robot tool with the patient's soft tissues. The robot "felt" the patient, memorized its body contours, elasticity, then calculated the massage trajectories and reproduced them using its drives. The standard robot control system, designed for the positional and continuous-path control, could respectively implement the algorithms for separate position-force control. The robot used individual classical massage methods and acupressure techniques for the dummies, dogs, and human volunteers. This robotic massage method was protected by a patent [3].
Subsequently, the developed domestic robotic manipulation complex was improved under the auspices of the State Industrial University and the National Medical Research Center for Rehabilitation and Balneology of the Ministry of Healthcare of [4]. The robotic arm software was developed on the basis of the OMRON TM5-700 collaborative robot (Japan). Moreover, a diagnostic strain-algorithmometric unit, an equipment assembly designed to make a three-dimensional model of the human body surface and a temperature scanning system (temperature mapping of the patient's body surface) were added.
Later, the similar manipulative robots were developed at the Massachusetts Institute of Technology, Beijing University, Kin Teck Tong Singapore Medical Center, where the devices were clinically tested on the patients with traumatic epicondylitis, back pain and neck stiffness, as well as other pathological conditions [7; 8; 9; 10].
However, when implementing the proposed robotic systems, the following organizational and technical problems still remain unresolved:
- improvement of the product design and aesthetic appeal;
- development of the most simple and convenient user interface with a visual display of both the examination results and the manipulation methods;
- mathematical description of massage techniques;
- development of a system that allows to create programs using a set of massage techniques and movements;
- determination of the variability limits for each massage technique (general and individual) in various body zones;
- development of a system and algorithm for quick and easy nozzle changeover;
- improvement of the safe relations system for the robot and human interaction;
- formation of the fundamentals to develop a new specialty, such as a masseur-operator of robotic systems.
- In addition to the aesthetic criteria that are necessary in the medical institutions, the robotic arm design shall also be based on the ethical principles of robotics [5]. Thus, a robot assistant, and a robot for massage manipulations, belongs to this category:
- they shall not have an anthropomorphic shape (shall not awake fear, disgust and base instincts in a person, both a patient and an operator);
- they shall not replace a similar human function without its improvement and expansion (shall not repeat human stupidity and limitations);
- they shall not generalizing conclusions that go beyond the scope of the program (shall not make independent decisions that could lead to the consequences significant for a person).
In an attempt to solve at least some of these problems, if not all of them, in 2021 Beautyliner Group, proposed the Robosculptor robotic massage complex (Fig. 1) for practical use that was based on a collaborative robotic arm equipped with a massage nozzle, a high-speed time-of-flight (FoT) camera for making the patient 3D images, an infrared camera for solving the patient’s body recognition problems, a platform for the robotic arm movement along the human body, as well as an adjustable couch, a supporting unit frame and other auxiliary systems.
Figure 1. General view of the Robosculptor robotic massage complex
Arrangement of a robotic massage procedure can be based on three approaches.
The first approach is that after the patient's 3D scanning procedure, the specialist shall use interface for selection of an individual massage program from the set of available standard massage combinations, with due regard to the individual patient’s specifications. When the program is launched, it shall be automatically applied by the robot to the patient in accordance with the specified parameters.
The second approach is to train the robotic arm to repeat the massage movements with a given force, dynamics and trajectory after the specialist. For this purpose, by moving the nozzle using the master handle in the spatial demonstration mode, the specialist shall set the massage tool movement trajectory along the patient's body surface. Due to the fact that at the time of trajectory recording, the patient's body position is simultaneously monitored by the FoT camera, it is possible to combine data obtained by projecting the instrument movement trajectory onto the patient's body surface. This method allows to dynamically adjust the massage trajectories in the case of changes in the patient’s body position of the body or posture during the session. The given bionic approach to the control makes it possible to bring the robot activity closer to the typical actions of an experienced human masseur.
The procedure in this case is as follows: the specialist analyzes the primary information relating to the patient. The patient then lies on the couch, and the operator moves the handle fixed to the end robot unit and deforms the underlying soft tissues in accordance with the specified exposure method. The exposure time is set programmatically and the automated procedure protocol is commenced.
The software algorithm for biotechnical robotic arm control for massage is shown in the diagram.
The first approach is that after the patient's 3D scanning procedure, the specialist shall use interface for selection of an individual massage program from the set of available standard massage combinations, with due regard to the individual patient’s specifications. When the program is launched, it shall be automatically applied by the robot to the patient in accordance with the specified parameters.
The second approach is to train the robotic arm to repeat the massage movements with a given force, dynamics and trajectory after the specialist. For this purpose, by moving the nozzle using the master handle in the spatial demonstration mode, the specialist shall set the massage tool movement trajectory along the patient's body surface. Due to the fact that at the time of trajectory recording, the patient's body position is simultaneously monitored by the FoT camera, it is possible to combine data obtained by projecting the instrument movement trajectory onto the patient's body surface. This method allows to dynamically adjust the massage trajectories in the case of changes in the patient’s body position of the body or posture during the session. The given bionic approach to the control makes it possible to bring the robot activity closer to the typical actions of an experienced human masseur.
The procedure in this case is as follows: the specialist analyzes the primary information relating to the patient. The patient then lies on the couch, and the operator moves the handle fixed to the end robot unit and deforms the underlying soft tissues in accordance with the specified exposure method. The exposure time is set programmatically and the automated procedure protocol is commenced.
The software algorithm for biotechnical robotic arm control for massage is shown in the diagram.
Diagram. General diagram of the biotechnical control algorithm.
The third approach is based on the use of artificial intelligence tools. Due to the availability of a significant sample collection, it is possible to perform not only the patient’s body segmentation, but also to determine its anthropometric parameters. It is also possible to prepare the massage programs with due regard to the individual patient features.
The robotic system development program involves the development and use of various massage manipulators.
At present, the working tool of the robotic complex is a massage nozzle containing a rotating drum. It consists of the massage silicone spheres with a diameter of 20 mm, combined into 10 groups of 6 spheres. The groups of spheres are located on the drum with the mutual displacement to provide a high microcompression degree when interacting with the patient’s soft tissues. The spheres rotate freely on the drum axes, have a smooth surface and have a hardness of 70-80 according to the Shore A scale. The adjustment range of the drum rotation speed is from 100 to 450 rpm and is monitored by an electronic control system.
The similar massage roller is used in the Beautylizer device. The efficiency of this method is confirmed by scientific research (please provide the link).
The third approach is based on the use of artificial intelligence tools. Due to the availability of a significant sample collection, it is possible to perform not only the patient’s body segmentation, but also to determine its anthropometric parameters. It is also possible to prepare the massage programs with due regard to the individual patient features.
The robotic system development program involves the development and use of various massage manipulators.
At present, the working tool of the robotic complex is a massage nozzle containing a rotating drum. It consists of the massage silicone spheres with a diameter of 20 mm, combined into 10 groups of 6 spheres. The groups of spheres are located on the drum with the mutual displacement to provide a high microcompression degree when interacting with the patient’s soft tissues. The spheres rotate freely on the drum axes, have a smooth surface and have a hardness of 70-80 according to the Shore A scale. The adjustment range of the drum rotation speed is from 100 to 450 rpm and is monitored by an electronic control system.
The similar massage roller is used in the Beautylizer device. The efficiency of this method is confirmed by scientific research (please provide the link).
Figure 2. Handpiece of the Robosculptor robotic massage complex
Due to the use of this massage nozzle, it is possible to apply all 4 groups of massage techniques (frottage, kneading, foulage, vibration) depending on the adjustable instrument force level when touching the patient's body surface.
The possible uses of the robotic massage complex have already been implemented for elimination of the aesthetic defects of soft tissues. However, its prospects of use are much greater.
In medical practice, there is a need for short-term massage procedures limited in terms of impact. Thus, the medical rehabilitation programs for the patients with injuries and musculoskeletal disorders require the typical massage manipulations in relation to the thighs, lower legs, shoulders, thoracocervical spine, etc., as a part of measures preceding or completing the use of other restorative treatment methods (therapeutic exercises, instrumental physiotherapy).
Moreover, according to the Order of the Ministry of Healthcare of the No.788n dated July 31, 2020 “On Approval of the Procedure for Medical Rehabilitation of Adults”, since September 01, 2023 the organizational charts of medical rehabilitation departments shall delegate the functional duties of nurses in terms of massage, physiotherapy and therapeutic exercises to the nurses majoring in medical rehabilitation. However, they are not able to perform the same scope of works, especially with the same quality, as the subject matter experts. It is expected that the hardware robotic technologies should be included in their field of activity as much as possible, thereby minimizing the need for highly skilled manual labor.
Thus, there is a critical question about training the specialists who are able not only to use the manual massage procedures and the mechanotherapeutic treatment methods, but also to maintain the robotic equipment and know the fundamentals of programming in various environments.
At present, further development and improvement of robotic systems for the soft tissue manipulation as a medical diagnostic complex can lead to a new approach to the dosed, and, accordingly, strictly scientific use of manual exposure in the wide clinical practice, and especially in medical rehabilitation. In turn, it breaks new grounds in the development and improvement of both the massage and manual therapeutical techniques and methods, and even these specialties themselves, at the background of the 4th technological revolution [11].
The possible uses of the robotic massage complex have already been implemented for elimination of the aesthetic defects of soft tissues. However, its prospects of use are much greater.
In medical practice, there is a need for short-term massage procedures limited in terms of impact. Thus, the medical rehabilitation programs for the patients with injuries and musculoskeletal disorders require the typical massage manipulations in relation to the thighs, lower legs, shoulders, thoracocervical spine, etc., as a part of measures preceding or completing the use of other restorative treatment methods (therapeutic exercises, instrumental physiotherapy).
Moreover, according to the Order of the Ministry of Healthcare of the No.788n dated July 31, 2020 “On Approval of the Procedure for Medical Rehabilitation of Adults”, since September 01, 2023 the organizational charts of medical rehabilitation departments shall delegate the functional duties of nurses in terms of massage, physiotherapy and therapeutic exercises to the nurses majoring in medical rehabilitation. However, they are not able to perform the same scope of works, especially with the same quality, as the subject matter experts. It is expected that the hardware robotic technologies should be included in their field of activity as much as possible, thereby minimizing the need for highly skilled manual labor.
Thus, there is a critical question about training the specialists who are able not only to use the manual massage procedures and the mechanotherapeutic treatment methods, but also to maintain the robotic equipment and know the fundamentals of programming in various environments.
At present, further development and improvement of robotic systems for the soft tissue manipulation as a medical diagnostic complex can lead to a new approach to the dosed, and, accordingly, strictly scientific use of manual exposure in the wide clinical practice, and especially in medical rehabilitation. In turn, it breaks new grounds in the development and improvement of both the massage and manual therapeutical techniques and methods, and even these specialties themselves, at the background of the 4th technological revolution [11].
References:
- Analytical review of the robotics market. - National Association of Robotics Market Members: Sberbank Robotics Laboratory, 2019. - 272 p.
- Gerasimenko M.Yu., Eremushkin M.A., Arkhipov M.V., Kolyagin Yu.I., Antonovich I.V. Development prospects of robotic manipulation mechanical treatment complexes // Physiotherapy, balneology and rehabilitation. - 2017. - Vol. 16, No. 2. - Pp. 65–69.
- Golovin V.F., Arkhipov M.V., Zhuravlev V.V. Robotics in restorative medicine. Robots for mechanotherapy. LAP LAMBERT Academic Publishing, GmbH & Co. KG, 2012, 280 p.
- Razumov A.N., Samorukov A.E., Eremushkin M.A., Golovin V.F. Main trends and prospects for the clinical use of robotic systems for soft tissue manipulation. - 2004. – No.2. - Pp. 5-7.
- Savelieva E.M., Eremushkin M.A. Robotic massage: opportunities and prospects. Arbat readings. Issue 3: collection of research papers. — Znanie-M, 2020. — Pp. 58-67.
- Development strategy of the medical industry of the for the period up to 2020. Ministry of Industry and Trade ofation, 2010. - 61 p.
- AiTREAT ROBOTICS: Expert Manipulative Massage Automation // Electronic data. URL access mode: https://www.aitreat.com/about-emma (access date: April 30, 2020).
- Donlon M. Debut of robotic masseuse in Singapore // Electronic data. URL access mode: https://insights.globalspec.com/article/6755/debut-of-robotic-masseusein-singapore (access date: May 05, 2020).
- Kok L. Robot therapist hits the spot with athletes // Electronic data. URL access mode: https://media.ntu.edu.sg/NewsReleases/Pages/newsdetail.aspx?news=7ab9433d-a40d-46ba-9803-c30d99cd9355 (access date: May 05, 2020).
- Momi E.D., Segato A., Autonomous robotic surgery makes light work of anastomosis, Science Robotics, 7, 62, (2022). /doi/10.1126/scirobotics.abn6522.
- Schwab K.M. The Fourth Industrial Revolution // Foreign Affairs dated December 12, 2015. URL: https://www.foreignaffairs.com/articles/2015-12-12/fourth-industrial-revolution.
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