The Role of Haptics in Pediatric Rehabilitation

Ellyana Sungkar

Department of Physical Medicine and Rehabilitation, Dr. Hasan Sadikin General Hospital,

Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.

Keywords: Haptic, Haptics Technology, Pediatric Rehabilitation, Disability

Abstract: Haptic is derived to the Greek word that means the sense of touch. Haptic is consisted of kinesthetic and

tactile. Areas of Haptics are divided into machine, computer and human haptics. In haptic technology,

human sense of touch have coupled with computer and used mainly in creating and controlling virtual

objects. Haptics technology can be used to train people for task requiring hand-eye coordination. Haptic

interface is included as haptics technology, it is a system that allows a human to interact with a computer

through bodily sensations and movements. Haptics in medical rehabilitation has a primary purpose to

recover or improve the impairments. Haptics is proven to be beneficial in medical rehabilitation for

disability children to improve their haptic perception development, overall cognitive and social interaction

in the long term. In conclusion, Movement disorders in children are causally and clinically heterogeneous

and present in a challenging developmental contexts. The haptics technology should be categorized as the

complement of conventional therapy in pediatric rehabilitation that motivating, allows for high repetition

therapy, and improves outcomes recording and feedback.

1 INTRODUCTION

Rehabilitation science has recently shown that

intense and longer physical rehabilitation trough

repeating movement will benefit even chronic

patients. Robots are ideal in this kind of situation,

because they are not only can train patients for the

required long duration without tiring (unlike human

therapists), but also lead to a reduction in labor costs

(Burdea,2010). Basic development theory of robotic

rehabilitation is the Haptic Technology.

The meaning of Haptic Technology is the

technology of virtually touching and feeling the

objects and forces. It is a new emerging technology

from the area of virtual reality that allows computer

users to use their sense of touch to feel three-

dimensional virtual objects using haptic devices (D.

Naga, 2013).

Haptic is derived to the Greek word that means

the sense of touch. The word entered English in the

late 19th century as medical synonym of tactile

(ISO, 2011). The development of haptic in human

has been started since an early age and it is

important because it enables humans to perform a

wide variety of exploration and manipulation task.

Haptic is consisted of kinesthetics and tactile

receptors (Vera, 2016). The tactile aspect refers to

the static and information received from the nerve

terminals of the skin. Kinesthetic refers to the

dynamic aspects of interaction with the object

(Carter J).

There is also an idea which is developed by the

use of kinesthetic sense through receptors located in

the muscles, joints and tendons. These receptors also

allow the person to feel the force/torques exercised

upon contact with a body and to know where this

person’s hand within the space, even with his eyes

closed.( Coles, 2011) Tactile receptors such as

pressure, shear, and vibration, are sensed by

specialized sensory end organs known as

mechanoreceptors that are embedded in the skin.

The Cutaneous mechanoreceptors are localized

in the various layers of the skin where they can

detect a wide range of mechanical stimuli, including

light brush, stretch, vibration and noxious pressure

by touch.( Roudaut Y, 2012)

Touch itself is the detection of mechanical

stimulus impacting the skin, including innocuous

and noxious mechanical stimuli. It is a necessary

sense for the survival and the development of mam-

Sungkar, E.

The Role of Haptics in Pediatric Rehabilitation.

DOI: 10.5220/0009064401050110

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 105-110

ISBN: 978-989-758-409-1

105

mals and human.( Roudaut Y, 2012) Touch is a

compound sense because it represents different

tactile qualities, namely, vibration, shape, texture,

pleasure and pain, with different discriminative

performances.

Haptic also affected by mechanoreceptors. The

aptitude of mechanoreceptors is to detect mechanical

cues relies on the presence of mechano-transducer

ion channels that swiftly transform mechanical

forces into electrical signals and depolarize the

receptive field. This local depolarization, called

receptor potential, can generate action potentials that

promulgate toward the central nervous system.

There are four main functions that contributing

in human haptic perception: somatosensory

sensation, manual and in-hand manipulation,

cognition and vision (ISO, 2011).

The role of somatosensory sensation in haptic

reaction is to developed a body scheme to help the

interpretation of object’s spatial properties, then to

manage manual and in hand manipulation during

active touch. The role of Manual and in hand

manipulation is to generate exploratory actions from

the information from motor command, produces

tactile feedback needed for object acknowledgment.

The role of cognition is to understand and

acknowledge the world to develop the inquiry of

environment. The Role of vision is to help learning

and recognize object characteristics (ISO, 2011). All

of them above are use in haptic extrimity

rehabilitation device.

The extrimity rehabilitation are devided in two

two groups the upper one and the lower one. The

upper extremity rehabilitation focus to improving

the patient’s shoulder, elbow, wrist, and fingers and

the patient’s activities of daily living. Lower

extremity training focus to exercising the patient’s

knee, ankle, foot, or the whole leg in walking.

Robots have been used in physical rehabilitation for

more than a decade, and they focused all of the

above areas of therapy. A Major goal in point of

view of rehabilitation is to help children with

movement disorders in understanding the limits of

the human body and help them interact in the

physical environment. (B. Smits-Engelsman, 2013)

2 DISCUSSION

2.1 Human Haptic System

Human Haptic system is consist of the human sense

of touch include a closed loop system of receptors

sensing, transmitting messages to and from the

brain, thinking, and manipulating. Haptic interfaces

needs electromechanical and computer-based

system. (SPIE)

2.1.1 Areas Of Haptic

Basically, a haptic system formed of two parts,

namely, the human part and the machine part. Both

the systems include Sensor, processors, and Actuator

control circuitry. A sensor is accountable for sensing

the haptic information exerted by the user on a

certain object and sending it to haptic rendering

module. The actuator will read the haptics data sent

by the rendering module and transform this

information into a form of perceivable by human

beings.(Moradabad, 2014)

2.1.2 Haptics Interfaces

Haptics interface system will allow human to

interact with a computer trough bodily sensation and

movements. Haptic Interface uses fully duplex

channel, you can both transmit and receive

information simultaneously.(Technopedia) There are

two types of haptic interfaces the first one is tactile

and the second one is force feedback technology

Haptic Interfaces.(Cohen YB)

Haptic Interface Scan is divided into two main

groups from the point of view of the sensation they

can create at the moment of contact with the part of

the body, those which create kinesthetic stimuli and

those which create tactile stimuli.(Bilgincan, 2010)

2.2 Tactile Technology

Tactile Technology known as touch screen, is a

device that is responsible of stimulating the nerve

receptors of touch to display, in the interaction with

human skin. Tactile will feel vibration and pressure.

Vibration and pressure are the familiar

mechanical receptors stimulated in Tactile

Technology.(Garcia Hernandez N, 2014)

There are some parameters used in tactile

technology and contribute in tactile feedback such as

temperature, coarseness, shape, and texture.(Sato K,

2010)

Tactile feedback in the tips of fingers can help in

increasing the degree of immersion of the user in

virtual environment.(Zasulich, 2016)

There have also been a progress using tactile

technology called by electro cutaneous interfaces. It

uses the principle of electrostimulation of the nerve

endings on the surface of the skin. These interfaces

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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tend to be small, substantial, efficient and there are

free of mechanic resonance.

2.3 Force Feedback Technology

The kinesthetic or force feedback Haptic Interfaces

(HIs) demonstrates behaviors indistinguishable to

robot mechanisms with which the user interacts and

exchanges mechanical energy.

The way of the kinesthetic HIs are mechanically

built under two great categories related to the way

the force feedback applied (via links and tension

elements). The first are compact in size and portable,

while the other one are large. The most commonly

used interface is the linked element one, where the

rigid elements are linked to each other until the final

effector are activated by electric engines located at

the base of the device.(Jose-LuisRodriguez, 2012)

The second interface group has the transference of

force through tension cables, given the exerted force

via motors in continuous and its movement is

graduated by movement via digital decoders

connected to them.(Sato K, 2010)

Tabel 1: Summary of Technologies Applied in Kinesthetic

Haptic Interfaces(Zasulich, 2016)

Technology Actuator

Mechanism

Contact Zone

Pneumatic Piston Direct support

to extremities

Hydratic Piston Direct support

to extremities

Electric DC motor directly

connected or by

cables and pulleys

Arm, hand

wrist or fingers

Magnetic Lorentz principle

levitation

mechanism

Hand, fingers

In this second group, a haptic exoskeleton is also

established. This is another type of interface for the

transference of force that was developed some time

back and is based on tension cables by motors and

position decoders. The support for these devices can

be on the floor, wall, desk or on the user’s body and

can attain more than six degrees of freedom in the

workspace.(Sabater J.M, 2010)

2.4 Haptic Manipulation Strategies In

Infants

There are several development in infant haptic and

motoric reflex. We all know that baby from 2 – 3

months will experiencing oral exploration, grasping,

hand mouth coordination. Arm and hand movement

develops fast during this stage. What was once a

tight, clenched fist is now an open hand grabbing

and batting object. Babies explore their hands by

bringing them in front of their face and putting them

in their mouths.(John M)

Baby from 4 to 6 months old will have a vision

reflex as the initial exploration modality, and

fingering behaviour.

Baby from 7 to 9 months old will bang the hard

objects, and can hold fingered textured object. Baby

from 9 to 12 months old can turn and rotate the

object using their both hands.(Mersch)

In the first months of baby life, they try to adjust

manipulative behavior to objects characteristics

(rigidity, texture, shape, weight, movable part, etc)

and when they get older the haptic and motor skill

will develop and help baby to explore a variety

surface.(Ardiel EL, 2010)

2.5 Evaluation Of Haptic Perception In

Infant

As children grow, they intuitively learn more

sophisticated manual activities as a result of proceed

hand functions.

In children with disabilities who cannot reach,

grasp and directly manipulate objects due to their

physical limitations, perceptual development can be

delayed compared with typically developing

children of the same age.(Nooshin J, 2016)

There is no standardized assessments to assess

haptic perception in children with disabilities, that’s

why there are approach about the developmental

assessment coupled with criteria of referenced

procedures and process oriented to coup with that

issue.

The standardized assessment only about to

examine accuracy of haptic perception. The non-

standardized assessment is to examine the way the

child approaches a task, the effect of task on their

nature haptic style / strategy.

2.6 The Use Of Haptic For Human

The results perceived a remarkably strong case for

haptics’ ability to influence appeal and interest for

human use. Many of the study’s subjects indicated

content haptics were more approachable and

persuasive. They also know that haptics is adding to

their positive memory of the experience. Participants

across a wide range of demographics, ages, and

technology affinities rated their experience and the

The Role of Haptics in Pediatric Rehabilitation

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products they observed with haptics at 18% higher

when it came to quality of experience. The study

also showed that an 11% increase in brand value,

and an average 40% increase of condition recall

compared to non-haptic experiences. The

diversification and depth of additional insights

provided data points on how the human brain reacts

to general and specific levels of tactile exposure. In

The end, it proved that applying haptics is highly

effective at transfer a user’s attention from one

experience to a more emotionally compelling

environment. Haptics can make greater the visual

and auditory user’s experience by creating sensory

immersion in rich and compelling tactile effects that

are fully showed in video, virtual reality, augmented

reality, and many other formats. Touch and sensory

experiences are a major part of the human brain, and

the sense of touch-enabled by haptic technology

produces a meaningful and lasting sense of

experiential emotional reality for the brain. The

pragmatic and lasting effects of haptic design,

confirm that it creates memorable and impression-

based interactions that not only influence our

reactions but also deeply connect us emotionally to

the digital experience of the moment.(Immersion)

Table 2 : The benefit haptics for human

Haptics

Influence

recognition and

perception

11% (Brand Recognition) + 18%

(perception quality)

Haptics are an

effective mode

of persuasion

8% higher motivation and

engagement responses

Haptics

Intensity

emotion

The frequency and density of

haptics affect the level of

emotional response. In a study,

haptics impacted arousal but an

average of 6% compared to

standard condition

Haptics

Improve

Memory

High motivation and arousal both

indicate an optimal level of mental

effort, which facilitate memory

encoding and overall desirability

2.7 Haptic In Medical Rehabilitation

The problem of rehabilitation is to motivate patients

to exercise consistently, so as to achieve the goals of

rehabilitation, haptic can be used when treating

children with movement disorders.

Haptic feedback used in physical therapy is

different from that provided to able-bodied users due

to the force and motor coordination deficits of the

disabled, because it’s usually in the form of resistive

forces which include graphics and other simulation

modalities (Burdea,2010).

Haptic makes more movement therapy of body

limbs by the use of control interfaces. It can provide

a more intensive and effective therapy that need less

mediation of a therapist compared with one-on to

one therapies. (Gokeler A, 2014)

The primary motive of haptic use in medical

rehabilitation is to have recovery or improvement of

impairment. There are several haptic that is used in

rehabilitation such as haptic exotendon for hand

rehabilitation, customized haptic interfaces for blind

people in computer interactions, customized haptic

joystick for motor and cognitive

impairment.Nooshin J, 2016)

Recent recommendations affirm that there are

two aspects that play a central role in haptic

feedback for physical rehabilitation, assistive haptics

and disturbances(Burdea,2010).

Assistive Haptics is used by the patient who had

a neurological disorder (stroke, spinal injury,

cerebral palsy). In rehabilitative assistive

technologies, the primary purpose of intervention is

recovery or improvement of impairment.

Haptic disturbances are effects overlaid in the

simulation in order to increase therapy difficulty or

induce desired after effects. For example in the

Rutgers Ankle CP which is one of haptic devices

from the Rutgers Physical Rehabilitation Institute,

air turbulence was simulated when piloting the

airplane during a storm by oscillating the Rutgers

Ankle in the horizontal plane. Tests showed that

patients gradually learned to cope with these haptic

disturbances, eventually being able to clear 100% of

the target hoops. This is indicative of improved

ankle control (Burdea,2010).

2.8 Haptic Technology In Medical

Setting

In multimodal haptic guidance systems in medical

setting have been accompanied by visual and/or

auditory sensory information to enhance the

perception and task performance of people with

disabilities. (Jafari N, 2016)

This haptic guidance system is used in several

devices. For example that is use in Serious Games

(SG) based therapies for Upper limb. The function

of this device is to optimize neuro-rehabilitation in

CP children. It increase engagement and provide

rich, congruent multi-sensory feedback during

virtual interaction.(Bortone, 2016)

Providing the haptic feedback in a virtual

environment appears to be a feasible approach to

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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improve cerebral palsy children's handwriting

skills.(Choi KS, 2011)

The earliest applications of haptics in upper

extremity rehabilitation is the MIT MANUS one of

the commercial robotic for upper extremity that was

released at the Burke Rehabilitation Hospital, NY

1994. The patient rests their forearm on a special

support with safety coupling that detaches in case of

excessive forces, then the patient is strapped in a

chair in order to prevent compensatory torso leaning

and faces a monoscopic display controlled by a PC

(Burdea,2010).

After The MIT MANUS there is a development

of prototype called The Rutgers Master II Glove

only weighs about 100 grams. The Rutgers Master II

has an exoskeleton that provides one degree of force

feedback per finger. The glove uses a direct-drive

configuration and compressed air, so that each

fingertip is resisted in flexion with up to 16 N force.

This Glove is faster and easier than the previous

one(Burdea,2010).

While robots for upper extremity rehabilitation

have existed, those used to train the patient’s

walking and ankle control are more infrequent. The

robots for lower extremity uses the same treadmill

and Body Weight Support approach, but adds a pair

of leg exoskeleton robots, which assist the gait cycle

with speeds up to about 3 km/h(Burdea,2010).

There is also a robotic ankle therapy for children

with CP, that is proved to improve plantar flexor and

dorsi flexor ROM, strength, spasticity, mobility,

balance (Paediatric Balance Scale), and Selective

Control Assessment of the Lower Extremity

(SCALE).(Moulton S, 2014)

For children with Down syndrome and

developmental disabilities, there is a commercial

prototype of a multimodal guidance system called a

PHANToM interface. It uses haptic guidance to

assist the user’s hand movements in sketching a

template shape by tracing its contours in a virtual

environment. Then, the sketched shape was printed

on a piece of foam and haptic feedback assisted to

cut it out using a hot wire tool connected to the

PHANToM device. This device equipped with an

audio feedback related to the hand’s velocity and

position. Participants’ precision of operation was

assessed before and after being guided by sound and

haptic feedback.(Covarrubias M, 2011)

Using all of the robotic and haptic devices can

make a possibility that children with disabilities may

experience improving haptic perception

development, potentially leading to improved

overall cognitive and social interaction in the long

term.(Atashzar SE, 2017)

2.9 The Downsides Of Haptics

There are some of the disadvantages of the haptic

technology such as higher cost, complex in nature,

large weight and size, crude experience, requires

advance design.(Mathur P, 2014)

3 CONCLUSIONS

Movement disorders in children are causally and

clinically heterogeneous and present in a challenging

developmental context.

The patients were able to accomplish and

motivated trough rehabilitation session with the

support from haptic use. Haptic help increase the

therapy dosage and reduce the supervision and lead

us to improve cost benefit profiles.

The haptic technology should be categorized as

the complement of conventional therapy in pediatric

rehabilitation that motivating, allows for high

repetition therapy, and improves outcomes recording

and feedback. Intensive rehabilitation is necessary

for improving motor function in children with

movement disorders.

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