Abstract:
System, method and apparatus for carrying out isometric exercises for therapeutic purposes. As employed in a therapeutic mode the apparatus may only be programmed within mandated therapeutic parameter limitations. During therapeutic trials, the user is visually and aurally cued throughout the test sequence and the therapeutic data evolved during the regimen is recorded and recoverable from archival memory. Particular target force modes can be selected to allow stimulation of nitric oxide release, and modulation of serum lipid composition.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application is a continuation-in-part of copending application Ser. No. 10/268,363 filed Oct. 10, 2002 and claims the benefit of Provisional Application No. 60/330,265, filed Oct. 18, 2001. 
     
    
     STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH  
       [0002]     Not applicable.  
       BACKGROUND OF THE INVENTION  
       [0003]     The use of isometric as compared to rhythmic exercise in the general field of athletic strength development, as well as a therapy for strength recovery has been the subject of somewhat controversial discourse over the past decades. In general, such exercise has been considered to promote, for example, coronary risk factors. See generally: 
        (1) Vecht R J, Graham G W S, Sever P S. “Plasma Noradrenaline Concentrations During Isometric Exercise.”  Brit Heart J.  1978;40:1216-20.     (2) Chrysant S G. “Hemodynamic Effects of Isometric Exercise in Normotensive Hypertensive Subjects”:  Hypertension. Angiology  1978:29(5):379-85.        
 
         [0006]     However, as such attitudes persisted, some investigators commenced to observe contradictions to these generally accepted beliefs. See for, example, the following publications: 
        (3) Buck, et al., “Isometric Occupational Exercise and the Incidence of Hypertension”,  J. Occup. Med.,  27:370-372, 1985     (4) Choquette. et al., “Blood Pressure Reduction in ‘Borderline’ Hypertensives Following Physical Training”  Can. Med. Assoc. J.  1108:699-703, 1973.     (5) Clark, et al., “The Duration of Sustained Contractions of the Human Forearm of Different Muscle Temperatures”,  J. Physiol.,  143:454-473, 1958.     (6) Gilders, et al., “Endurance Training and Blood Pressure in Normotensive and Hypertensive Adults”,  Med. Sci. Sports Exerc.  21:629-636, 1989.     (7) Hagberg, et al., “Effect of Weight Training on Blood Pressure and Hemodynamics in Hypertensive Adolescents”,  J. Pediatr.  1104:147-151, 1984.     (8) Harris, et al., “Physiological Response to Circuit Weight Training in Borderline Hypertensive Subjects”,  Med. Sci. Sports Exerc.,  19:246-252, 1987.     (9) Hurley, et al., “Resistive Training Can Induce Coronary Risk Factors Without Altering Vo 2 max  or Percent Body Fat”  Med. Sci. Sports Exerc.  20:150-154, 1988.     (10) Hypertension Detection and Follow-up Program Cooperative Group, “The Effect of Treatment on Mortality in ‘Mild’ Hypertension”,  N. Engl. J. Med.,  307:976-980, 1982.     (11) Kiveloff, et al., “Brief Maximal Isometric Exercise in Hypertension”,  J. Am. Geriatr. Soc.,  9:1006-1012, 1971.     (12) Merideth et al., “Exercise Training Lowers Resting Renal but not Cardiac Sympathetic Activity n Humans”,  Hypertension,  18:575-582, 1991.     (13) Seals and Hagberg, “The Effect of Exercise Training on Human Hypertension: A Review”, Med. Sci. Sports Exerc. 16:207-215, 1984.     (14) Hanson P. Nagle F. “Isometric Exercise: Cardiovascular Responses in Normal and Cardiac Populations.”  Cardiology Clinics  1987; 5(2): 157-70.        
 
         [0019]     Such speculation on the part of these early observers was confirmed by Wiley in the 1990s, as described in U.S. Pat. No. 5,398,696 entitled “Isometric Exercise Method for Lowering Resting Blood Pressure and Grip Dynamometer Useful Therefore”, issued Mar. 21, 1995 and as described in the following publication: 
        (15) Wiley, et al., “Isometric Exercise Training Lowers Resting Blood Pressure”,  Med. Sci. Sports Exerc.  29:749-754, 1992.        
 
         [0021]     With the approach of protocol developed by Wiley, the isometric regimen is closely controlled both in terms of exerted force and in the timing of trials or exertions. The system and method described by Wiley are known to be useful for treating hypertension. Hypertension is associated with an increased risk of a wide range of disease and disorder, including stroke, organ failure, and particularly cardiopathy. The exact causes of hypertension are rarely known with certainty, but risk factors for hypertension include obesity, genetic factors, smoking, diet and inactivity. As Wiley has shown, not all forms of exercise provide equivalent therapeutic benefit to the cardiovascular system and for the treatment of hypercholesterolemia, with a protocol for brief maximal isometric exercise providing a clear benefit.  
         [0022]     Hypertension, hypercholesterolemia, atherosclerosis and cardiovascular disease hare interrelated in their causes, treatment and effect on the body. The class of drugs known as HMG-CoA reductase inhibitors or statins is widely prescribed for treatment of hypercholesterolemia and associated cardiovascular disease, including the debilitating effects of progressive atherosclerosis. Various statins that have been clinically utilized include atovastatin, cerivastatin, fluvastatin, ovastatin simvastatin among others. The statin drugs were initially prescribed to relieve hypercholesterolemia, and to reduce the blood concentrations of low-density lipoprotein (LDL) and triglycerides. It has become apparent that the statin drugs apparently have additional therapeutic benefits that are independent and or interrelated with the effects of reduction in blood cholesterol concentration. The effect of statin drugs thus includes a reduction in vascular inflammation, and a protection of the heart against ischemic disorders. For more information on the pleiotropic effects of the statin drugs see generally: 
        (16) Davignon J., “Beneficial cardiovascular pleiotropic effects of statins.”  Circulation.  109 (23 Suppl 1):III39-43 (2004).     (17) Elrod J W, Lefer D J The effects of statins on endothelium, inflammation and cardioprotection.  Drug News Perspect.  18(4):229-36 (2005, May).     (18) Assanasen C, et al., Cholesterol binding, efflux, and a PDZ-interacting domain of scavenger receptor-BI mediate HDL-initiated signaling.  J Clin Invest.  115(4):969-77 (2005 April).        
 
         [0026]     Although the exact mechanism of statin drug action for cardioprotection is not fully known, it is widely believed that statin drugs stimulate nitric oxide synthase activity in vascular endothelium, and presumably in other tissues. Disorders of the vascular endothelium related to in nitric oxide metabolism are believed to play a crucial role in the pathogenesis of atherosclerosis in hypercholesterolemia. Thus, certain cardioprotective effects of statin drugs can be mimicked in part by other physiological stimuli that induce nitric oxide synthase and increase nitric oxide availability. Moreover, nitric oxide metabolism is interconnected with the metabolism and regulation of LDL, cholesterol and triglycerides, and with the progress of atherosclerosis. As one example of this interrelationship, changes in nitric oxide levels have been inversely correlated with changes in LDL-cholesterol concentrations.  
         [0027]     Nitric oxide (NO) has been identified as a signaling molecule in mammalian and other systems. NO, is a labile, endogenously produced gas that is enzymatically synthesized, can rapidly diffuse, and quickly disappear. NO is known to be a potent regulator of blood pressure due to its activity as a vasodilator, but has a diverse action on a wide variety of organ systems. Endothelial nitric oxide synthase (eNOS) is induced to synthesize NO by blood vessel wall shear stress. Upon the activation of eNOS and induction of NO synthesis, NO is released by endothelial cells. Based on the position of endothelial cells lining the inner surface of blood vessels, NO can be released into the blood stream, where it can act both locally and systemically. NO induces vasodilation by a reduction in the contraction of smooth muscle cells lining blood vessels. NO acts as a negative feedback for mean arterial pressure, since as arterial pressure increases, wall shear stress increases, inducing eNOS and increasing the NO concentration. As NO concentration increases, smooth muscle contraction is decreased, blood vessel lumen diameter increases, arteriole resistance decreases and arterial pressure decreases. The modulating action of wall shear stress on eNOS activity and NO production serves to maintain wall shear stress at a constant level. A diagram highlighting some of the interactions between NO, local metabolites, wall shear stress and smooth muscle contraction is shown in  FIG. 20 .  
         [0028]     Prolonged elevation of wall shear stress, in addition to activation of eNOS, leads to the transcriptional activation of the eNOS gene in endothelial cells. After several hours, eNOS enzyme levels increase due to the induced transcription of the eNOS gene. Increased levels of eNOS enzyme in endothelial cells increases those cells ability to release NO following induction of eNOS activity. It is thus expected that those cells which have experienced prolonged elevation of wall shear stress will have an increased ability to synthesize NO, and the same levels of wall shear stress will result in a greater synthesis of NO. One effect of increased eNOS levels is a reduction in the amount of wall shear stress that is required to induce biologically significant NO levels. Blood vessels that have been entrained by prolonged elevation of wall shear stress will release more NO relative to shear stress, and the vasodilation effect of NO will be increased, Higher relative NO concentration leads to reduced smooth muscle contraction, increased blood vessel lumen diameter and decreased arteriole resistance. Assuming that the cardiac output of the heart does not change, the net effect of a lower “set point” for responding to wall shear stress is a reduction in total peripheral resistance in blood vessels and a reduction in mean arterial pressure.  
         [0029]     Similar to the effects of the statin drugs, an improvement in endothelial function is interconnected with LDL and cholesterol blood levels and NO bioavailability. LDL and cholesterol have been shown to prevent the down-regulation of eNOS. In turn, down-regulation of eNOS is apparently mediated by the stimulation of levels of caveolin-1 by LDL. Caveolin-1 is an important inhibitor of eNOS catalytic activity. Modulation of NO is expected to affect the interrelated blood lipid concentrations of VHDL, HDL, LDL, and cholesterol. To the extent that the pleiotropic activity of the cholesterol lowering statin drugs is modulated by NO levels, stimulation of NO bioavailability is expected to affect blood lipid composition. For additional background on the interrelationship between LDL and NO, see generally: 
        (19) Martinez-Gonzalez, J., et al.,  Arterioscler. Thromb. Vasc. Biol.  21: 804-809 (2001).        
 
         [0031]     As described above, it has been known for some time that exercise can provide relief from hypertension in certain individuals. As the modulation of nitric oxide levels is part of a feedback system that responds in part to the stretching and extensibility of blood vessels of the body, it is hypothesized that exercise in general plays a role in stimulating cycles of NO release, and effectively providing some of the benefits of statin drugs, including improvement in endothelial function, increased nitric oxide bioavailability, anti-oxidant effects, anti-inflammatory protection, and stabilization of atherosclerotic plaques. Notwithstanding the effects of the modulation of NO bioavailability, exercise is known to modulate blood cholesterol and blood lipid composition.  
         [0032]     There is widespread discourse on the relative benefits of particular forms of exercise. There is an ongoing need for patients suffering from hypertension, hypercholesteremia, atherosclerosis, and other cardiovascular and cardiopulmonary diseases to obtain the maximum benefit from the exercise utilized. Patients who are suffering from severe cardiovascular disease may be unable to engage in intense exercise, and many patients may be unable to engage in other forms of exercise due to limitations in time or facility availability. The invention disclosed herein provides for a device, system and method of exercise that can be optimized to provide an improved benefit to the patient in stimulating endothelial function, overall blood vessel health, and cardiovascular benefit while at the same time limiting the dangerous side effects of intensive exercise.  
         [0033]     In contrast to the approach of Wiley, earlier subjects or trainees undergoing isometric exercise stressed the involved musculature to their full or maximum capability (publication (11)) or at some submaximal force as long as it could be sustained, in either case only terminating with the onset of unendurable fatigue. Such approaches often have incurred somewhat deleterious results as evidenced by the injuries sustained in consequence of improper weightlifting procedures. Weightlifting procedures or endeavors exhibit a significant isometric factor. See generally: 
        (20) Lind A R. “Cardiovascular Responses to Static Exercise”( Isometrics, Anyone? ) Circulation 1970:41(2):173-176.     (21) Mitchell J H, Wildenthal K. “Static (Isometric) Exercise and the Heart: Physiological and Clinical Considerations”.  Ann Rev Med  1974;25:369-81.        
 
         [0036]     The diagnosis of patient hand-arm strength using isometric-based testing has been employed by physiologists, physical therapists and medical personnel for over three decades. These procedures function to evaluate hand-arm trauma or dysfunction and involve the patient use of a handgrip-based dynamometer. The dynamometer is grasped by the patient and squeezed to a maximum capability under the verbal instruction of an attending therapist or diagnostician. The hand dynamometer most widely used for these evaluations incorporates a grip serving to apply force through closed circuit hydraulics to a force readout provided by an analog meter facing outwardly so as to be practitioner readable. Adjustment of the size of the grip of the dynamometer is provided by inward or outward positioning of a forwardly disposed grip component. The dynamometers currently are marketed under the trade designation: “Jamar Hydraulic Hand Dynamometer” by Sammons Preston of Bolingbrook, Ill. An extended history of use of these dynamometers has resulted in what may be deemed a “standardization” of testing protocols. For instance, three of the above-noted grip length adjustments are employed in a standardized approach and verbal instructions on the part of the testing attendant, as well as the treatment of force data read from the analog meter are now matters of accepted protocol. In the latter regard, multiple maximum strength values are recorded whereupon average strengths, standard deviations and coefficients of variation are computed by the practitioner. In one test, the instrument is alternately passed between the patient&#39;s right and left hands to derive a maximum strength output reading each 1.5 seconds or 2.5 seconds. Reading and hand recording strength values for such protocols has remained problematic. The protocols, for example, have been the subject of recommendations by the American Society of Hand Therapist (ASHT) and have been discussed in a variety of publications including the following: 
        (22) Mathiowetz V., Federman S., Wiemer D. “Grip and Pinch Strength: Norms for 6 to 19 Year Olds.”  The American Journal of Occupational Therapy  40:705-11, 1986.     (23) Mathiowetz V., Donohoe L., Renells C. “Effect of Elbow Position on Grip and Key Pinch Strength.”  The Journal of Hand Surgery  10A;694-7, 1985.     (24) Mathiowetz V., Dove M., Kashman N., Rogers S., Volland G., Weber K. “Grip and Pinch Strength: Normative Data for Adults.”  Arch Phys Med Rehabilitation  66:69-72, 1985.     (25) Mathiowetz V., Volland G., Kashman N., “Reliability and Validity of Grip and Pinch Strength Evaluations.”  The Journal of Hand Surgery  9A:22-6, 1984.        
 
         [0041]     In about 1998, the above-noted Wiley protocols as described in connection with publication (12) above were incorporated in a compact, lightweight isometric device. Described in detail in U.S. Pat. No. 5,904,639 entitled “Apparatus, System, and Method for Carrying Out Protocol-Based Isometric Exercise Regimens” by Smyser, et al., the hand-held dynamometer has a hand grip which incorporates a load cell assembly. Extending from the hand grip is a liquid crystal display and two user actuated control switches or switch buttons. The display is mounted in sloping fashion with respect to the grip such that the user can observe important visual cues or prompts while carrying out a controlled exercise regimen specifically structured in terms of force values and timing in accordance with the Wiley protocols. This device is therapeutic as opposed to diagnostic in nature and is microprocessor driven with archival memory. External communication with the battery powered instrument is made available through a communications port such that the device may be configured by programming and, additional data, such as blood pressure values and the like may be inserted into its memory from an external device. Visual and audible cueing not only guides the user through a multi-step protocol but also aids the user in maintaining pre-computed target level grip compression levels.  
         [0042]     Of course, it will be beneficial to incorporate improved diagnostic features for hand-arm evaluation techniques with therapist or practitioner designed therapeutic protocols specifically tailored to the condition of a given patient and which provide a control over such therapies clearly establishing such therapies as beneficial to strength development and recovery. One particular diagnostic and therapeutic feature that would be beneficial to incorporate is protocol that modulates wall shear stress of blood vessels so as to increase the bioavailability of nitric oxide and foster a reduction in total peripheral resistance in blood vessels and a reduction in mean arterial pressure, along with the other physiologic benefits associated with stimulation of NO signaling pathways, including reduction in LDL and cholesterol concentrations and an increase. in arterial flexibility.  
       BRIEF SUMMARY OF THE INVENTION  
       [0043]     The present invention is addressed to a system method and apparatus for carrying out a controlled isometric regimen by a user. Being microprocessor driven, the instrument is programmed to carry out established diagnostic as well as newly developed grip-based isometric regimens. When employed for carrying out a diagnostic maximum grip test, the diagnostician selects configuration parameters and the instrument provides both visual and audible prompts and cues throughout the procedure. Maximum grip forces for each of the sequence of trials of this procedure are selected typically by the diagnostician and when so selected are recorded in instrument memory along with calendar data, and processor computed values for average grip force, standard deviation of the force values throughout a sequence of tests and corresponding coefficients of variation. At the termination of the diagnostic procedure, memory recorded test data are displayable to the diagnostician and may be downloaded through a communications port to a computer facility.  
         [0044]     For each of the diagnostic procedures, the widthwise extent of the instrument grip may be both varied in standard ½ inch increments from a minimum width. The grip is further configured such that the visually perceptible readout of the instrument may be viewed only by the diagnostician where deemed appropriate.  
         [0045]     An important aspect of the therapeutic method associated with the instrument of the invention resides in the limiting of user performance to carry out the regimen of trials. In this regard, the instrument is programmed to perform only within predetermined and mandated test limits. Each therapeutic regimen is based upon an initial evaluation of the maximum gripping force capability of the user. Under that limitation, target load factors, hold on target load intervals, intervening rest intervals and trial repetition numbers may be elected only from pre-established and mandated memory retained ranges. The program also nominates rest intervals and hold on target intervals in correspondence with user elected target force factors. Thus, valuable strength recovery and development may be achieved but only within safe limits.  
         [0046]     During each of the above therapeutic regimens, an audible warning is elicited whenever the user grip force value exceeds a computed upper limit. During each timed interval wherein the user is prompted to grip at a target force value computed with respect to the pre-tested maximum grip force, a dynamic bar graph and center point display is provided as a visual cue related to desired grip performance. Additionally, a rapid succession of score values are computed and the average thereof recorded at the end of each trial of a given regimen. These scores permit a therapist to access the quality of the performance of the user. In general, trial data is recorded in conjunction with calendar data and, as before, may be downloaded to a computer facility from an instrument contained communications port.  
         [0047]     An additional object of the invention is to influence biological parameters of the user by selecting target loads that stimulate particular biological pathways. In one target force mode, the invention allows stimulation of nitric oxide bioavailability, which directly influences resting blood pressure and overall cardiovascular health. In other instances, the target force mode can be directed to maximize the exercise benefit for modulating blood lipid composition, including reducing low density lipoprotein (LDL) and cholesterol in the blood.  
         [0048]     Other objects of the invention will, in part, be obvious and will, in part, appear hereinafter.  
         [0049]     The invention, accordingly, comprises the method, system and apparatus possessing the construction, combination of elements, arrangement of parts and steps which are exemplified in the following detailed description.  
         [0050]     For a fuller understanding of the nature and objects of the invention, reference should be made to the following detailed description taken in connection with the accompanying drawings. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0051]      FIG. 1  is a perspective view of apparatus according to the invention showing its orientation with respect to a users hand wherein its display is viewable by such user;  
         [0052]      FIG. 2  is a perspective view of the apparatus of  FIG. 1  showing the orientation of the apparatus with respect to the users hand wherein the display thereof is not visually accessible to the user;  
         [0053]      FIG. 3  is an exploded perspective view of the apparatus of  FIG. 1 ;  
         [0054]      FIG. 4  is a side sectional view of the apparatus of  FIG. 1 ;  
         [0055]      FIG. 5  is a side view of the apparatus of  FIG. 1  showing a minimum grip width configuration;  
         [0056]      FIG. 6  is a side view of the apparatus of  FIG. 1  showing an orientation for user viewing of its display and a grip widthwise extent ½ inch greater than the grip orientation of  FIG. 5 ;  
         [0057]      FIG. 7  is a side view of the instrument of  FIG. 1  showing an orientation for user viewing of its display and illustrating a grip widthwise extent of maximum value;  
         [0058]      FIG. 8  is a side view of the instrument of  FIG. 1  showing an orientation for diagnostic viewing and a grip widthwise extent corresponding with that of  FIG. 6 ;  
         [0059]      FIG. 9  is a side view of instrument of  FIG. 1  showing a display orientation for viewing of a display by a diagnostician and having a grip widthwise extent corresponding with that of  FIG. 7 ;  
         [0060]      FIG. 10  is a block diagrammatic drawing of the circuit employed with the apparatus of  FIG. 1 ;  
         [0061]      FIG. 11  is a flow chart describing the start up components of the program of the instrument of  FIG. 1  as well as a configuration routine;  
         [0062]      FIGS. 12A and 12B  combine as labeled thereon to provide a flow chart of a maximum grip test diagnostic procedure;  
         [0063]      FIG. 13  is a flow chart illustrating a rapid exchange diagnostic procedure;  
         [0064]      FIGS. 14A-14C  combine as labeled thereon to illustrate a flow chart describing a therapeutic fixed exercise regimen carried out by the instrument of  FIG. 1 ;  
         [0065]      FIG. 15  is a flow chart demonstrating the technique by which a score value is developed by the apparatus of the invention;  
         [0066]      FIGS. 16A-16E  are a sequence of displays provided by the instrument of the invention showing a publication of score, a dynamic bar graph with center pointer and a time remaining cue;  
         [0067]      FIGS. 17A-17C  combine as labeled thereon to illustrate a flow chart of a step therapeutic exercise which may be carried out with the instrument of the invention;  
         [0068]      FIG. 18  is a flow chart showing an intentional power off sequence; and  
         [0069]      FIG. 19  is a flow chart describing the applicability of the use of isometric exercise in conjunction with safe muscle strengthening and therapy protocols for a broad range of muscle groups.  
         [0070]      FIG. 20  is a flow chart describing the interrelationship between mean arterial pressure, tissue pressure, perfusion pressure, heart rater, wall shear stress and nitric oxide levels.  
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0071]     Isometric exercise apparatus under which the methodology of the invention may be carried out is lightweight, portable, battery powered and sufficiently rugged to withstand the compressive pressures which it necessarily endures during use. The instrument is programmable such that it may be utilized by a therapeutic practitioner for diagnostic purposes employing established grip test modalities. Strength measurements carried out during these modes are compiled in memory and the practitioner is afforded calculated values for average grip force, standard deviation and coefficient of variation with respect to grip force trials. Furthermore, individual strength measurements compiled in these averages, whether taken rapidly or slowly, are stored in memory and may be reviewed by the therapist.  
         [0072]     Additionally, the instrument is employable as a therapeutic device. First a protocol is nominated by prescribing nominal parameters of the effort. Each isometric regimen is controlled initially by requiring that a maximum grip strength be established for each individual patient or user. Then, the practitioner may elect parameters of grip force and timing under mandated memory contained parameter limits. Accordingly, the user will be unable to carry out strength enhancement therapies which would otherwise constitute an excessive grip force regimen. For carrying out the noted diagnostic procedures as well as therapy activities, the grip widthwise extent is variable from 1⅞ inches to 2⅞ inches, such variation being adjustable in ½ inch increments. This is in keeping with standardized diagnostic practices. Further with respect to diagnostic procedures, the display or readout of the instrument can be adjusted with respect to the grip structuring such that only the practitioner or therapist may observe the data which is being developed during a diagnostic protocol.  
         [0073]     Looking to  FIG. 1 , the instrument or apparatus is represented generally at  10  as having a housing identified generally at  12 . Housing  12  is formed of acrylonitrile butadiene styrene (ABS) and, thus, is resistant to impact phenomena and the like.  FIG. 1  shows that the housing  12  includes a hand grasping portion  14  and an integrally formed interacting portion  16 . Interacting portion  16  supports a readout assembly  18  which is configured as an elongate liquid crystal display (LCD). Additionally located at the interacting portion are two finger actuable switches represented generally at  20 . Of these switches, switch  22  is designated as a “menu” switch, while switch  24  is designated as a “select” switch. Note that the readout assembly  18  is angularly oriented with respect to the grip axis  26  of the apparatus  10 . With this configuration, the user may observe prompts and cues appearing at the readout  18  as represented by the symbolic user eye station  28  and line of sight represented symbolically at arrow  30 . In this regard, note that the hand  32  of the user is grasping the hand grasping portion  14 . For the arrangement shown, the hand grasping portion  14  is represented as exhibiting its largest widthwise extent, i.e., 2⅞ inches. To gain this larger widthwise extent, auxiliary grip components  34  and  36  are employed in conjunction with the hand grasping portion  14 . These auxiliary grip components will be seen to be removable as well as universally positionable so as to provide the noted widthwise adjustments in ½ inch increments.  
         [0074]     Referring to  FIG. 2 , the instrument  10  is shown as it is employed for diagnostic activities. For this purpose, the auxiliary grip components  34  and  36  as seen in  FIG. 1  have been reversed in their orientation at hand grasping portion  14 . Note, additionally, that the symbolic eye station at  38  is now that of the diagnostician with a line of sight as represented symbolically at arrow  40  addressing the readout  18  (not shown). Note that the line of sight  40  is directed toward the auxiliary grip component  36  and the data readout for diagnostic purposes is not visually available to the user whose hand is represented at  32 . Seen additionally in  FIG. 2  is a serial communications port  40  and a battery compartment access cover  42 . The serial port offers, for diagnostic purposes, the instantaneous transfer of real-time data to remote monitoring and data archiving equipment.  
         [0075]     Looking to  FIG. 3 , an exploded perspective view of the apparatus  10  is provided. In the figure, the grasping portion  14  is seen to be comprised of two mirror image sides  52  and  54 . Integrally molded with the sides  52  and  54  are the two housing components of the interactive portion  16  as shown respectively at  56  and  58 . Plastic inserts or plugs are shown at  60  and  62  which are insertable within respective screw cavities  64  and  66 . Extending from grasping portion side  54  is an integrally molded screw receiving post  68 . In similar fashion, screw receiving post  70  is integrally formed with and extends from component  58 . Additionally, a screw receiving post  72  extends from component  58 . Post  72  receives a screw inserted through a battery cavity  74  inwardly disposed from cover  42 . Post  72  additionally functions to contribute to the support of a printed circuit board  76  by virtue of its insertion through an aperture  78  formed therein. Note that the printed circuit carrying board  76  also supports communications port  40 . In this regard, the port  40  extends into a rectangular opening  80  formed within interactive portion  58  of housing  12 . Further extending inwardly from component  52  are two force plate support plates  53  and  55   
         [0076]     Disposed centrally within the cavity defined by gripping portion sides  52  and  54  is a steel thrust plate  82  having a thickness and rigidity elected to withstand compressive gripping forces which may range, for example, up to about 205 pounds. Plate  82  is configured with two holes  81  and  83  which are used to restrain the plate from disengaging from the assembly when fitted over respective posts  53  and  55 . Elongate side  84  of thrust plate  82  is configured for insertion within an elongate groove  86  of a base grip component  88 . Grip component  88  is formed of a rigid plastic and includes an outwardly disposed base grasping surface  90  upwardly located in adjacency with the grasping surface  90  is one component of a base connector assembly represented generally at  92  and which is seen to be integrally molded with the grip component  88  and incorporates a slot or opening  94  in conjunction with a tab receiving trough  96 . A tab component (not shown) of the base connector assembly feature of the base grip component  88  will be seen to extend from the end thereof opposite connector assembly component  92 .  
         [0077]     Two oppositely disposed edge extensions  98  and  100  of the trust plate  82  are configured for operative association with a load cell assembly represented generally at  102 . Load cell assembly  102  includes an elongate steel base  104  incorporating two slots for receiving extensions  98  and  100 , one such slot being revealed at  106 . Connection between the base  104  and thrust plate  82  is provided by pins (not shown) which extend through mated bores  108  and  110  and  112  and  114 . The load cell assembly  102  further includes an elongate outer force component  116 . Two field plate-form load cells  118  and  120  are mounted from load cell mount structures shown, respectively at  122  and  124  formed within base  104 . Such mounting is in cantilever fashion, the load cell  118  being attached to mount  122  by a screw and mounting plate assembly  126 . Similarly, load cell  120  is attached in cantilever fashion to mount structure  124  by a screw and mounting plate assembly  128 . Outer force component  116  is seen to have a centrally disposed rectangular post portion  120  which is attached by a connector plate assembly to the mutually inwardly extending ends of the load cells  118  and  120 . the attachment plate assembly for this union is seen in general at  132 . Assembly  132  is seen to be formed of two plate components  132   a  and  132   b  coupled, in turn, to load cells  120  and  118 . Screws are used to effect the attachment.  
         [0078]     The base grip component positioned oppositely of base grip component  88  is shown at  134 . In similar fashion as component  88 , the base grip component  134  is configured with a base connector assembly having one component at  136  which incorporates a slot and trough (not shown) in similar fashion as described at  92  in connection with component  88 . a tab protrusion of generally cylindrical configuration shown at  138  is disposed oppositely from connector assembly component  136 . The rigid plastic base component  134  is attached to elongate outer force component  116  of the load cell assembly  102 . This attachment is provided by the insertion and crimping of two posts  134   a  and  134   b  ( FIG. 4 ) within respective holes  117  and  119  formed within force component  116 . a slot in component  1134  is provided to positively locate it onto the outer profile of component  116 . In general, posts  134   a  and  134   a  ( FIG. 4 ) are inserted through holes  117  and  119  and then melted with a hot iron to mechanically secure the two pieces  134  and  116  together as one sub-assembly. With the arrangement shown, gripping compressive force is asserted from the base component  188  through the thrust plate  82  into the load cell assembly  102 . This force is counteracted by gripping force asserted from base gripping component  134 .  
         [0079]     Auxiliary grip component  34  is shown in the figure in spaced adjacency with respect to the base grip component  134 . Auxiliary component  34  is configured with an outwardly disposed auxiliary grasping surface of generally half cylindrical cross section with a grasping surface profile curved concavely outwardly, for example, at region  140 . This curvature is provided for enhancing grip contact with the palm of the user hand and for applying force centrally to the load cell assembly. Component  34  is formed with an auxiliary connector assembly which includes a flexible engaging tab  150  configured for insertion within the connector component  136  of base grip component  134 . Connection at the opposite end is provided by a curved slot (not shown) which receives the tab protrusion  138  of base grip component  134 . The connector assemblies are universal such that each of the auxiliary grip components may be mounted upon either of the base grip components  88  or  134 . In this regard, not that a similar flexible engaging tab  152  is positioned upwardly upon auxiliary grip component  36 . Similarly, the component  36  is configured having a curved slot  154  at its opposite end which receives tabs, for example, as at  138 . The mounting of either auxiliary grip component  36  or  34  will increase the widthwise extent of the grip by one half inch. Accordingly, with both auxiliary grip components installed, the widthwise extent of the grip is increased to 2⅞ inches.  
         [0080]     Interacting region  16  also includes a top cover  156 . Formed, as the other components, of ABS plastic, the cover  156  includes a rectangular bezel opening  158  within which the LCD  18  is positioned. Integrally formed with top cover  156  is a downwardly depending switch cover  160  through which two rectangular openings  162  and  164  are provided. The switching function  20  is mounted upon a separate circuit board  166  which is seen to carry two push actuated switches as earlier described at  22  and  24  and identified by the same numeration in the instant figure. Located over the switches  22  and  24  is a flexible polymeric cover  168  formed of a flexible polymeric material such as Santoprene, a thermoplastic elastomer marketed by General Polymers of Charlotte, N.C. Circuit board  166  is supported between two slots formed in the interior of side components  56  and  58 , one of these slots is seen at  170 . The LCD  18  is mounted upon a circuit board  172  supported in turn, from interactive components  56  and  58 . A bus-type wiring harness electrically associates the switching function  20 , LCS  18 , load cell assembly  102 , the battery within compartment  74  and the circuitry carried by circuit board  76 .  
         [0081]     A sectional view of the instrument  10  is provided at  FIG. 4 . In the figure, base grip component  88  is shown in conjunction with base connector assembly component  92 . In that regard, the slot  94  again is revealed as well as the tab receiving trough  96 . At the opposite end, the base connector assembly includes an outwardly extending arcuate tab  174 . Auxiliary gripping component  36  is shown coupled to the base grip  88 . Note that the auxiliary component  36  has a grasping surface  176 , the profile of which is undulatory to provide a finger grasping configuration. This undulatory profile further functions to provide a finger grasping configuration which centers the gripping force on handle  88 . The lower portion of the base grip component  88  is seen to be formed having an outwardly extending arcuate tab  174  which slideably nests within the corresponding arcuate slot  154  in auxiliary grip  36 . The connector assembly for base grip component  134  is identical. In this regard, the component  134  includes an arcuate outwardly extending tab  138  and a slotted receiver  136  structured identically as that described at  92 . Auxiliary grip component  34  is connected to base grip component  134  by sliding a protruding tab or tongue  138  into arcuate slot  178 . Additionally, the flexible engaging tab  150  is shown extending through a slot in connector component  136 .  
         [0082]      FIGS. 5-7  illustrate variations of grip widthwise extent available for utilization of instrument  10  in conjunction with therapeutic protocols. In general, for such therapeutic protocols, the readout assembly  18  is arranged to face the eye station of the user. In  FIG. 5 , no auxiliary grip components are mounted upon either base grip component  88  or base grip component  134 . Accordingly the widthwise extent of the grip is 1⅞ inch. Looking to  FIG. 6 , the palm engaging auxiliary grip component  34  is shown mounted over base grip component  134 . The increases the widthwise extent of the grip for therapeutic applications to 2⅜ inches.  FIG. 7  illustrates the utilization of both auxiliary grip components  34  and  36  to provide a grip widthwise extent of 2⅞ inches. As before, the auxiliary grip components are arranged such that the user may observe readout  18 .  
         [0083]      FIGS. 8 and 9  illustrate grip arrangements particularly suited for diagnostic purposes wherein the diagnostician has exclusive access visual to the readout assembly  18 . In  FIG. 8 , base grip component  134  is combined with auxiliary grip component  34  to provide a widthwise grip extent of 2⅜ inches. Removal of the auxiliary grip component  34  returns the grip widthwise extent to 1⅞ inches.  
         [0084]     In  FIG. 9 , both auxiliary grip components  34  and  36  are employed to provide a maximum widthwise grip extent of 2⅞ inches. It may be observed in  FIGS. 8 and 9  that the positioning of the auxiliary grips is reversed in the sense of the grip configuration shown in  FIGS. 5-7 .  
         [0085]     Turning to  FIG. 10 , a block diagrammatic representation of the controller components of instrument  10  is revealed. In general, the instrument  10  is microprocessor driven, for example, employing a type 8051 microprocessor as represented at block  180 . The controller is powered by a standard 9 volt battery. That voltage then is regulated to 5 volts for use by the circuit components. A power supply to the strain gauge implemented load cells  118  and  120  is dropped by a resistor such that the maximum current applied is limited to 50 milliamps. Such power supply is represented in the figure at block  182  which, in turn, is seen to be associated with microprocessor  180  via line  184  and with switch  24  via lines  186  and  188 . Note that switches  22  and  24  respectively are labeled “menu” and “select”. Switch  24  serves the additional function of an on switch or enablement switch. Power also is seen to be supplied to the communications connector  40  as represented at line  190 . Communications connector  40 , in turn, is seen coupled to a communications driver  192  as represented at line  194 . Driver  192  associated with the microprocessor  180  as represented at line  196 . The microprocessor  180  also provides control over an annunciator or buzzer as represented at block  198  and line  200 . Similarly, control to the liquid crystal display (LCD)  18  from microprocessor  180  is represented at line  202 . A real-time clock is provided with the controller circuit as represented at block  204 . Time and date data from that clock are used in conjunction with the monitoring and memory features of the instrument  10  such that important data, including date and time of a given trial regimen can be retained in memory and downloaded via the communications port  40  when called for. The association of the real-time clock function  204  and microprocessor  180  is represented at line  206 . Archival memory as well as temporary memory are provided with the controller. Archival memory may be provided, for example, as an electrically erasable programmable read only memory (EE PROM), an 8 kilobyte device which requires no power to sustain its memory retention, i.e., it is non-volatile. The archival memory is represented at block  208  and its association with the microprocessor  180  is represented at line  210 .  
         [0086]     Load cells  118  and  120  are represented with that numeration in  FIG. 10 . These load cells are each configured as a four resistance balance bridge-type load cell. The outputs of load cells  118  and  120  are directed to the amplification function as represented by respective lines  212  and  214  extending to amplifier block  216 . The output of amplifier  216  is represented at line  218  extending to an analog-to-digital converter function represented at block  220 . Correspondingly, output of the converter function  220  is directed to the microprocessor  180  as represented at line  222 . Microprocessor  180  converts the signal to a force value in pounds or kilograms which is displayed in the LCD  18 . The menu switch  22  is shown associated with microprocessor  180  via line  224 , while the select switch  24  is associated with that processing function as represented at line  188 .  
         [0087]     Each of the instruments  10  is calibrated using nineteen combinations of six standard weights. A best fit is determined and the instrument is called upon to have a root mean square error (RMS) of 0.1 pounds or less to pass calibration requirements. Once the calibration constants has been determined, the system is loaded with two redundant copies of the calibration constants. The zero point of the load cell is monitored at all times during the use of the instrument  10 . If a drift is found, then a warning is shown at the LCD display  18 . If any lead wire to the load cell becomes disconnected, then the built-in monitoring detects this occurrence, shows an error message, and disables further use of instrument  10  until the power is reset. These features insure that the force reading shown is accurate and true. Absolute values of the outputs of load cells  118  and  120  are summed to provide a force output signal. In general, the load measurement accuracy of instrument  10  is better than 0.1 pound of 0.1% of applied force whichever is greater.  
         [0088]     In the discourse to follow, the sequences of the program protocol carried out by instrument  10  are represented in flow chart fashion. In general, these flow charts commence with a configuration sequence if desired and then look to two diagnostic protocols followed by two therapeutic protocols.  
         [0089]     Turning to  FIG. 11 , the procedure seen to commence as represented at block  230  with the selection of the grip widthwise extent. In general, that grip width is elected to accommodate variations in user hand sizes. The program then continues as represented at line  232  and block  234  wherein, where appropriate, one or two auxiliary grip components as at  34  and  36  are installed in an orientation providing for user viewing of display  18  as illustrated in connection with  FIG. 1 , or in an arrangement for therapeutic practitioner viewing to the exclusion of the user as described in connection with  FIG. 2 . The program then continues as represented at line  236  and block  238  providing for the enablement of instrument  10  by actuation of select switch  24 . Upon such actuation, as represented at line  240  and block  242  a start-up message is provided at display assembly  18  for an interval of two seconds. Then, as represented at line  244  and block  246  a prompt is displayed at readout  18  identifying a default configuration wherein pounds as opposed to kilograms are elected; an audible tone is enabled, and for a diagnostic test referred to as “rapid exchange” wherein instrument  10  is passed from one hand of the user to the other and then back for a number of exchanges, the user providing a grip force trial at each exchange. The rapid exchange default values are ten exchanges with 1.5 seconds available for user griping or squeezing. Following the publication of the screen as represented at block  246 , should the user not actuate either the switches  22  or  24 , then as represented at line  248  and block  250  the instrument  10  will turn off or power down at the end of a five minute interval. This feature is always active, i.e., turning off five minutes after a last switch actuation.  
         [0090]     With the publication of the screen as represented at block  246 , then as represented at line  252  and block  254  the practitioner or user is called upon to determine whether to enter a configuration sequence or to progress to a diagnostic grip test. To enter the latter diagnostic grip test sequence, as represented at line  256  and block  258  by pressing switch  24  display  18  will prompt the user to press the select switch  24  to commence a diagnostic grip test sequence. Where the select switch  24  is actuated, then the program enters the diagnostic grip test sequence as represented at line  260  and node A.  
         [0091]     Where a determination on the part of the practitioner or user is made to enter a configuration sequence, then as represented at line  262  and block  264  the configuration sequence is entered by actuating switch  22 . As represented at line  266  and block  268  the initial configuration looks to units. Recall from block  246  that the instrument  10  defaults to a units evaluated in pounds. As represented at line  270  and block  272  by actuating select switch  24  the units parameter can be converted to kilograms instead of pounds. The program then continues upon depressing or actuating menu switch  22  as represented at either lines  274  or  276  leading to block  278 . As represented at block  278 , the user then is given the opportunity to delete the audible tone. In this regard, by actuating select switch  24 , as represented at line  280  and block  282 , the tone is deleted, display  18  showing the term “tone” in connection with the letter N.  
         [0092]     The configuration sequence then continues as represented at either lines  283  or  284  with the actuation of menu switch  22 . This actuation of switch  22  provides for the establishing of a rapid exchange diagnostic test cycle time change. As set forth at block  286  the default cycle time is 1.5 seconds. However, by actuation of select switch  24 , as represented at line  288  and block  290  the operator may change the cycle time to 2.5 seconds. The program then continues by actuating the menu switch  22  as represented at either of lines  292  or  294 . These lines lead to the configuration alteration represented at block  296 . Recall from block  246  that the default number of exchanges for the rapid exchange diagnostic procedure is  10 .  
         [0093]     However, as represented at line  298  and block  300  the operator may change the number of exchanges from 10 to 20 by actuation of select switch  24 . The program then returns to line  244  by actuation of the menu switch  22  as represented at lines  302  and  304 . As described in connection with block  258 , line  260  and node A, the operator may elect to proceed with a diagnostic grip test.  
         [0094]     Referring to  FIG. 12A , node A reappears in conjunction with line  306  extending to the query posed at block  308  wherein a determination is made as to whether or not to enter a diagnostic grip test mode. Where the operator determines that the diagnostic grip test mode should be entered, then as represented at line  310  and block  312 , the grip test mode is entered by actuating select switch  24 . The operator is then prompted at display  18  to actuate select switch  24  to enter a max test mode. Accordingly, with the actuation of switch  24 , as represented at line  314  and block  316  the maximum diagnostic grip test mode is entered. On the other hand, as represented at line  318  and node B by actuating the menu switch  22 , the practitioner may cause instrument  10  to enter a rapid exchange sequence.  
         [0095]     Returning to block  316 , the maximum strength grip test can be carried out with 10 maximum squeezing force trials. At the conclusion of a given number of such trials, the practitioner actuates select switch  24 , whereupon computations are carried out. Accordingly, as represented at line  320  and block  322  the user is prompted with the message “squeeze hard!!!” at the readout  18 . The program will elect the highest force applied during such squeezing activity, whereupon the user releases the grip force as represented at line  324  and block  326 . Then instrument  10  will publish the maximum force applied by the user as represented at line  328  and block  330 , a first maximum grip evaluation being shown as an example as 64.4 pounds. Block  330  also indicates that the user is prompted to either actuate the select switch  24  to accept the published maximum squeeze evaluation as set forth at block  330  or to squeeze the grip  14  again. Such squeezing again will provide a substitute maximum grip force evaluation. Then, as represented at line  332  and block  334  the query is posed as to whether the select switch  24  has been actuated. In the event that it has not, then the program loops as represented at line  336  extending to line  320 , whereupon a maximum grip effort again is undertaken. Where the operator elects the maximum first trial grip force evaluation, then as represented at line  338  and block  340 , the program will compute an average of force values, standard deviation and coefficient variation, albeit it for one trial at this junction in the procedure.  
         [0096]     The program then continues as represented at line  342  and block  344  to display computed values which, as noted above, for the first trial are irrelevant. However, as the number of trials increases, those computed values gain significance. Next, as represented at line  346  and block  348  the program commences to carry out a next maximum grip test by providing a prompt at readout  18  which advises the user to “squeeze hard!!!” and indicates that this is a second trial as represented by the terms: “MAX 2”. Following a squeezing of the grip region  14 , as represented at line  350  and block  352  the user releases the grip force and, as represented at line  354  and block  356  the maximum force asserted by the user is published, for example, showing 60 pounds for a “MAX 2” trial. This prompt further advises the user to actuate select switch  24  to elect the published grip force value or to squeeze again to carry out a next trial. The program then continues as represented at line  360  and block  362  to determine whether or not select switch  24  had been actuated. In the event that it had not been actuated then the program loops as represented at lines  364  and  346  whereupon the user again may carry out the second maximum grip trial. Where switch  24  has been actuated, then as represented at line  366  and block  368 , the program carries out a computation of the average of the maximum forces asserted and computes standard deviation and coefficient of variation which are submitted to memory. The program then continues as represented at line  370  and block  372  whereupon the values computed in connection with block  368  are published at display  18 . The above maximum grip test trials may be reiterated for 10 trials. Accordingly, as represented at line  374  and block  376  the maximum test trials are reiterated for a total of N tests (10 maximum) and the computed values of average force, standard deviation and coefficient of variation are both submitted to memory and published at display  18 . As represented at line  378  and block  380  the user may restart this max test sequence following the Nth trial by actuating select switch  24 , whereupon the program returns as represented at line  382  to  310  ( FIG. 12A ). Returning to block  380 , by actuating menu switch  22 , as represented at line  384  and block  386 , a subsequent actuation of select switch  24  will return the program to a previous menu. As represented at line  388  and block  390  by again actuating menu switch  22 , as represented at line  392  the program reverts to node B as described in conjunction with  FIG. 12A . By again actuating select switch  24 , as represented at line  394  the program returns to entry into the maximum grip diagnostic test, line  394  extending to line  314  seen in  FIG. 12A . This circular logic is made available at a variety of locations within the program.  
         [0097]     Returning to  FIG. 12A , where the query posed at block  308  results in a negative determination that the maximum grip test diagnostic mode is not to be entered, then, by actuation of menu switch  22 , as represented at line  396  and block  398  a determination is made as to whether to exit a diagnostic mode and enter a therapy based mode. Where a therapy mode is not elected, then as represented at line  400  and block  402  a previous menu may be elected by actuating the select switch  24  as represented at line  404  and node D. By actuating menu switch  22 , then as represented at line  406 , the program loops to line  306  and the query posed at block  308 . Where a therapy mode is elected by the user, then as represented at line  408 , the program diverts to a therapy mode of performance as represented at line  408  and node E.  
         [0098]     Looking back to the query posed at block  334 , where the menu switch  22  is actuated as opposed to electing a maximum grip value, then as represented at line  410  and block  412  the program will reconfigure for restarting the grip test mode. Once at this point in the program as represented at block  412 , by again actuating select switch  24 , the program reverts as represented at line  414  to line  320  to carry out another maximum grip trial. On the other hand, where menu switch  22  is actuated, as represented at line  416  and block  418  an indication will be given to the operator that to elect previous menu, select switch  24  is to be actuated. As represented at line  419 , the program then reverts to node C. Node C again appears in  FIG. 12A  in conjunction with line  420  extending to line  310 . Where menu switch  22  is again actuated, the program reverts to block  412  as represented at line  422 .  
         [0099]     Looking again to  FIG. 12B  and the query posed at block  362 , where the second maximum grip test is not selected by menu switch  22  is actuated, then as represented at line  424  and block  426  the program enters a mode for restarting the maximum grip test. By again actuating menu switch  22 , as represented at line  428  and block  430  the user is prompted to enter the previous menu position in the program by actuating the select switch  24 . Accordingly, by actuating switch  24  as represented at line  432 , the program reverts to node C. Returning to block  426 , where the select switch  24  is actuated, then the program loops as represented at line  434 , to line  346  to again undertake the second of the maximum grip tests. By actuating menu switch  22  from the program location of block  430 , as represented at line  436  the program reverts to its position at block  426 .  
         [0100]     The diagnostic performance mode of the instrument  10  also provides for the carrying out of a rapid exchange (RE) test. With the rapid exchange test, the user may grip instrument  10  in the manner shown in  FIG. 2  such that the therapist or practitioner may observe readout  18  to the exclusion of the user or patient. With the rapid exchange, a maximum grip force is exerted by the user or patient in exchanging between the right and left hands under a controlled exchange timed cycle which will have been elected, for example, in connection with the configuration mode described in connection with  FIG. 11 . It may be recalled that the number of exchanges may also be elected by the diagnostician as 10 or 20 efforts or trials. The rapid exchange mode of performance is elected as represented at block  312  and line  318  extending to node B described in connection with  FIG. 12A . Node B reappears in  FIG. 13  in association with line  440  and block  442 . Referring to that figure, block  442  is seen to provide for a prompt to the practitioner to actuate select switch  24  to enter the rapid exchange mode. Upon actuating switch  24 , as represented at line  444  and block  446  a prompt is provided at readout assembly  18  advising the user to squeeze the grip  14  with the right hand to start the rapid exchange sequence. As represented at line  448  and block  450  the program awaits the presence of a right hand squeezing force. Until that squeezing force is asserted, the program dwells as represented at loop  452  extending to line  444 . Where a squeezing force is detected, then as represented at line  454  and block  456  the program commences to time out the succession of periods or time-hacks allocated for this cycle of the rapid exchange diagnostic procedure. That time interval may have been elected in the configuration mode as described in conjunction with blocks  286  and  290  ( FIG. 11 ). For example, the cycle time, T r  has a default value of 1.5 seconds or the last value selected.  
         [0101]     As represented at line  458  and block  460  the user will have squeezed the grip region  14  and the maximum hand force value evolved will be submitted to memory. Then as represented at line  462  and block  464  a determination is made as to whether the menu switch  22  has been actuated. In the event that it has not, as represented at line  466  and block  468  the program determines whether the Nth, i.e., 10 th  or 20 th  trial has been completed. In the event that it has not, then as represented at line  470  and block  472  the rapid exchange test has not been completed and an audible tone cue (time hack) is provided indicating that the instrument should be switched to the opposite hand. A short dwell occurs as represented at line  474  and block  476  wherein the instrument determines whether or not a squeeze force has been asserted. In the event that it has not, then the program loops as represented at line  478 . Where the user has imparted a squeezing force to the instrument, the program continues or loops as represented at line  480  extending to line  458  leading to a next trial in an alternate hand.  
         [0102]     Returning to block  464  where menu switch  22  is actuated in the course of carrying out rapid exchange trials, an affirmative determination will be made with respect to the query posed at that block. Accordingly, as represented at line  482  and block  484  the user is prompted to restart the rapid exchange test by actuating select switch  24 . Where select switch  24  is actuated, then as represented at line  486  the program reverts to line  444  and block  446 . On the other hand, where menu switch  22  is actuated, then as represented at line  488  and block  490  the user is prompted to revert to the previous menu by actuating select switch  24 . Where select switch  24  is so actuated, then the program reverts to node C as represented at line  492 . Note, additionally, that if menu switch  22  is actuated in conjunction with the prompt provided at block  442 , then as represented at line  494  the program reverts to line  488 . Returning to block  490 , where menu switch  22  is actuated then as represented at line  496  and block  498  the program computes and displays the overall average of the maximum trial values, standard deviation and coefficient of variation for the N trials. That data is submitted to memory. Should menu switch  22  be actuated at this juncture, then as represented at lines  500  and  482 , the program returns to block  484 . Where the select switch  24  is actuated, however, as represented at line  502  and block  504  the maximum force value for trial N and the average SE and CD for all trials is displayed. On the other hand, where the menu switch  22  is actuated, then as represented at lines  506  and  482 , the program reverts to block  484 .  
         [0103]     Where the select switch  24  is actuated repetitively, then as represented at line  508  and block  510  the succession of trials  1  through N is displayed. Additionally, the unchanging average for all those trials is displayed for convenience. Further, a query is posed as to whether the Nth trial has been displayed. Where it has not, then the display program loops as represented at line  512  extending to line  502 . On the other hand, where the Nth trial has been displayed, then as represented at line  514 , the program loops to line  502  to repeat the succession of displays.  
         [0104]     It may be recalled that in conjunction with block  398  in  FIG. 12A , a therapy mode may be entered by actuation of select switch  24  as discussed in connection with line  408  and node E. Node E reappears in  FIG. 14A  in conjunction with line  520  and block  522 . Block  522  indicates that the readout  18  will publish information that a grip therapy is available by actuation of select switch  24 . It may be recalled that the parameters of time and force are somewhat pre-established under the regimen of the instant program. In this regard, it is important that the isometric grip exercise be constrained within predefined force and time interval of holding and resting limits. These parameters are nominated in the program and while some variations are permitted, those variations are retained within physiologically determined limit values. Of importance of the grip therapy at hand, it may be observed that it is predicated upon the patient or users actual and unique the maximum gripping force which initially is evaluated and then treated by a preordained but still electable target valuation. In general, the prompt and cues provided at display  18  are made available to the patient or user by a handle configuration as described in conjunction with  FIG. 1 . Looking to  FIG. 14A , block  522  provides for a display at readout  18  indicating that a grip therapy mode is available by actuation of select switch  24 . As represented at line  524  and block  526  a determination is made as to whether a fixed mode of therapy or a stepped mode of therapy is to be elected. A fixed therapy is elected by actuation of select switch  24  as represented at line  527  extending to block  528 . Block  528  indicates that the fixed exercise configuration mode has entered. With such entry, as represented at line  530  and block  532  readout  18  prompts that the user will be given opportunities to adjust the target load factor, the number of repetitions of trials of the grip therapy, the duration of the holding of the grip force at a target value and the interval for a intergripping rest. However, as an initial component of the procedure, the maximum grip force value for a given patient is determined. Accordingly, upon actuating switch  24  as represented at line  534  and block  536  the user is prompted to squeeze the grip with maximum force by publishing the terms: “squeeze hard!!!”. Then, as represented at line  538  and block  540 , the squeeze generated load or force value is outputted to the microprocessor  180  ( FIG. 10 ). The maximum valuation of this initial force evaluation then is displayed at readout  18  as represented at line  542  and block  544 . In the latter block, it may be observed that a sample force valuation of 90.3 pounds is published at readout  18 . The user can elect that valuation as the maximum force value to be used in the program by actuating select switch  24  as represented at line  546  and block  548 . However, a prompt at readout  18  also provides that the user may retry this maximum grip force evaluation as represented at loop line  550  extending to line  538 . Where the user or therapist determines that an appropriate grip force has been derived, then as represented at line  552  and block  554  the elected maximum force value is submitted to memory and the program continues as represented at line  556  and block  558 . employing the elected maximum squeeze force, the program computes a target grip force using a default factor of 50%. Additionally, the program establishes a trial repetition number at a default number of 4; a hold on target force interval of 45 seconds; and a default rest interval of 120 seconds. As represented at line  560  and block  562  the computed target level then is displayed at readout  18  along with the value of the elected maximum grip force and the default target factor of 50%. The terms “Target 451 lb” blink as a prompt that the factor can be altered within an established range. The user or practitioner then is given the opportunity to adjust the target factor percentage in 10% increments from 10% to 100% as represented at line  564  and block  566  by actuating the menu switch  22 . Next, as represented at line  568  and block  570  the program computes at a new target value based upon the elected factor, an arbitrary designation “AA” being shown. A lower enabling grip force threshold also is derived. Should the user elect a target factor other than the 50% value by adjustment in connection with block  566 , the program will automatically nominate hold on target intervals and rest intervals for each available 10% selection from within the range from 10% to 100% which the user may have elected. This, again, is for the purpose of protecting the user from excessive effort intervals and inadequate rest intervals. However, still within the mandated overall ranges, the user or therapist can change those values for the hold on target effort and rest effort. The nominated hold or “Effort” and rest intervals contained in the program are summarized in Table 1 below.  
                                                   TABLE 1                       10%   20%   30%   40%   50%   60%   70%   80%   90%   100%       Max   Max   Max   Max   Max   Max   Max   Max   Max   Max                   120   120    90    60    45    15    12   10    5    3       sec.   sec.   sec.   sec.   sec.   sec.   sec.   sec.   sec.   sec.       Effort   Effort   Effort   Effort   Effort   Effort   Effort   Effort   Effort   Effort        60   120   120   120   120   120   120   60   60   60       sec   sec   sec   sec   sec   sec   sec   sec   sec   sec       Rest   Rest   Rest   Rest   Rest   Rest   Rest   Rest   Rest   Rest                  
 
 Following the target load computation, as represented at line  572  and block  573  the program displays the newly computed target force value at readout  18  along with the default values for number of repetitions (which defaults at 4), and the nominated hold on target interval and the rest interval (Table 1). As a prompt, the readout “4 REP” blinks to indicate that adjustment is available to the user. The program then continues as represented at line  574  which reappears in  FIG. 14B  extending to block  576  which provides for adjusting the number of repetitions between the values 1 and 10 by actuating menu switch  22 . Note that the maximum number of repetitions made available to the user is 10. The program then continues by actuating switch  24  as represented at line  578  and block  580  indicating that the computed target force level (AA) and the newly elected repetition number herein represented as “B” is provided at the display along with the nominated values for hold on target interval (CCC) and rest interval (DDD). In this display, the terms: “CCC HOLD” blink to prompt the user to make any desired adjustments within the mandated limits of from 5 seconds to 120 seconds. Accordingly, as represented at line  582  and block  584  the user or practitioner may adjust the hold on target interval by actuating menu switch  22 . When the desired hold on target interval has been displayed at readout  18 , the select switch  24  is actuated and the program progresses as represented at line  586  and block  588  to provide a display at readout  18  which indicates the computed target force level AA; the elected repetition number (B) and the elected hold on target interval (CCC). The display also will blink the terms “DDD REST” to prompt the user to adjust the rest interval to a desired value within the mandated interval range of 10 seconds to 120 seconds. Accordingly, as represented at line  590  and block  592  the user or practitioner can adjust (by decade components) the extent of the rest interval by actuating menu switch  22  until a desired interval value is displayed. Once the desired interval is so displayed, an actuation of select switch  24  will enter it into memory. Next, as represented at line  594  and block  596  the program displays the now elected values including the target force (AAIb); repetitions (B REP); the hold on target interval (CCC); and the rest interval (DDD). The program then provides a prompt to the user to start the therapy by actuating the select switch  24  as represented at line  598  and block  600 . Upon such actuation of switch  24 , as represented at line  602  and block  604  the program prompts the user at readout  18  to apply a gripping force at the target level along with the further prompt “squeeze”. Next, as represented at line  606  and block  608  the program determines whether the grip force applied by the user is within 10% of the computed target force value (AA). This is the lower threshold determination as described in conjunction with block  570 . In the event that the applied gripping force is not within 10% of the computed target value, the program loops as represented at line  610  extending to block  604  providing for a continuation of the prompt to hold on target. Where the applied grip force is within 10% of the computed target force value, then as represented at line  612  and block  614  the program commences to time out the hold on target interval previously elected or nominated (CCC) as discussed in connection with block  584 . While this hold on target force interval is underway, as represented at line  616  and block  618  a dynamic comparison value computation is carried out over a sequence of short time components within the hold time out interval. That comparison value is utilized in driving a bar graph form of display functioning to cue the user as to a proper grip force level. During this hold interval, as represented at line  620  and block  622  the program also compares the applied grip force with a force upper limit which is computed as 125% of the target force. In the event that the applied grip force is above that upper limit, then as represented at line  624  and block  626  an audible cue is sounded to warn the user that excessive force is being applied which is outside the proper protocol for the therapy. The program then continues as represented at lines  628  and  630  whereupon as set forth at block  632  a score as a percentage of target value is computed for a sequence of time increments. This score may be utilized by the user and the therapist for purposes of evaluating the quality of the exercise regimen carried out by the user. 
 
         [0105]     Turning momentarily to  FIG. 15 , a routine is depicted functioning to carry out the computation and display of the noted score values. This routine is entered into as represented at node  634  identifying it as a display of the score value. The routine commences as represented at line  636  and block  638  indicating that the currently applied grip force or load value is read as the user attempts to match the target force value. Then, as represented at line  640  and  642 , the score is determined by dividing that read force by the pre-computed target force and multiplying the result by 100 to provide the score as a percent. This score is developed for sequential increments of time, preferably each increment representing 1% of the hold on target interval (CCC). As represented at line  644  and block  646 , the score is converted into three display characters. Then, as represented at line  648  and block  650 , three characters representing the score are sent to readout  18  for display. The score may be above or below 100%, 100% representing an on target grip force.  
         [0106]     Returning to  FIG. 14B , the program continues as represented at line  652  which reappears in  FIG. 14C  extending to block  654 . Block  654  indicates that a display is provided at readout  18  which cues the user as to essentially instantaneous score value, the time remaining for holding on target and further cues the user as to the level of grip force being applied with respect to target through the utilization of a center pointer visual cue representing the target load value and an effort dynamic bar graph visual cue having a top position present as a bar graph top line. That top line will be aligned with the center pointer when the load value at output represents a force equal to the target load value. The top line will move away from the center pointer when the load value output or grip force exerted by the user represents a force which deviates from the target load value.  
         [0107]     Looking momentarily to  FIGS. 16A-16E , a representation of the display so provided for differing grip force activity is set forth. In  FIG. 16A , the dynamic bar graph extends to the right of the center pointer indicating a grip force which is too low. This lower grip force also is indicated by the lower score value of 62%. The display also includes an indication of the time remaining for the hold on target interval, for example, 100 seconds.  FIG. 16B  also indicates through the dynamic bar graph that the asserted grip force is still too low but improved over that shown in  FIG. 16A  as indicated by the shorter extent of the dynamic bar graph to the right of the center pointer and a higher score value of 75%.  FIG. 16C  shows a cue wherein the user grip force is at the target force, the top line of the bar graph being aligned with the center pointer and a score of 100% being displayed. Additionally, as before, the time remaining for the hold on target interval is displayed.  FIG. 16D  shows that an excessive grip force is being applied by the user, the dynamic bar graph extending to the left of the center pointer. This excessive force also is indicated by a score value of 125%. Time remaining in seconds within the hold on target interval also is displayed. finally,  FIG. 16E  shows a still more excessive application of grip force on the part of the user, the dynamic bar graph top line extending well to the left of the center pointer and a score of 137% being represented. As before, time remaining in the “on target interval” is also displayed.  
         [0108]     Returning to  FIG. 14C  the program is seen to continue as represented at line  656  and block  658  wherein a query is made as to whether the hold on target interval has timed out. In the event that it has not, then the program dwells as represented by loop line  660  extending to node I which reappears in  FIG. 14B  with line  662  extending to line  620 . In the event of an affirmative determination with respect to the query posed at block  658 , then as represented at line  662  and block  664  an audible cue is generated at the annunciator  198  ( FIG. 10 ). With the generation of this audible cue, then as represented at line  666  and block  668  the rest interval commences to be timed out. It may be recalled that the rest interval was elected in conjunction with block  592  ( FIG. 14B ). during this rest interval, as represented at line  670  and block  672  the program will provide a display at readout  18  which indicates the number of trials or efforts remaining in conjunction with the elected repetition value. At the termination of the first trial, that value will be B-1. The display also provides the average value of score and the interval of time remaining in the rest interval. Next, as represented at line  674  and block  576  a query is made as to whether the rest interval has timed out. In the event that it has not, then the program dwells as represented at loop line  678 . Where the query posed at block  676  results in an affirmative determination, then as represented at line  680  and block  682  an audible cue is generated and the program continues as represented at line  684  and block  686  providing for a reiteration of the trial sequence. As represented at line  688  and block  690  a query is made as to whether the elected number of repetitions of the trial (B) has been accomplished. In the event that that elected number of repetitions has not been completed, then the program dwells as represented at line  692 . In the event of an affirmative determination with respect to the query posed at block  690 , then as represented at line  694  and block  696  a final or average score is computed and submitted to archival memory in conjunction with calendar and force data. In the latter regard, each of the average grip force values asserted by the user for each trial are recorded. Next, as represented at line  698  and block  700  the program determines or selects an appropriate message of congratulation or warning base upon the computed final score. The program then continues as represented at lines  702  and block  704  to publish the selected message at readout  18  and continues as represented at line  706  to node G.  
         [0109]     Node G reappears in conjunction with line  708  ( FIG. 14A ) and block  526 . Where the user or therapist has determined to cause instrument  10  to enter into a stepped therapy mode, menu switch  22  is actuated as represented at line  710  and the program displays a prompt to the user as represented at block  712  indicating that the step therapy mode may be entered by actuating select switch  24  as represented at line  714  and node F.  
         [0110]     Referring to  FIG. 17A , node F reappears in conjunction with line  716  and block  718  providing for the entry of instrument  10  into a stepped exercise configuration mode. In this therapeutic mode the maximum grip strength unique to the user or patient is determined, whereupon the therapeutic gripping regime is one wherein the target load level as well as hold on target intervals and rest intervals vary in accordance the sequence of steps or gripping trials. The program opens as represented at line  720  and block  722  with a display at readout  18  prompting that the user is to be called upon to establish a maximum grip force level and carry out a setting of the number of steps and repetitions of the therapy. The user then actuates the select switch  24  and, as represented at line  724  and block  726  the program displays a prompt at readout  18  indicating that the user should carry out a maximum grip force exercise, the prompt including the terms; “squeeze hard!!!”. Then, as represented at line  728  and block  730  the user will have applied maximum squeezing force to the grip and that will have generated a load value output. While this load value output is being generated, as represented at line  732  and block  734  the program displays a cue at readout  18  which publishes the value of the maximum gripping force. Should the practitioner or user wish to attempt to improve that value, he or she is prompted to actuate select switch  24  and elect the value published or to squeeze the grip again. Where the user elects the value published, then as represented at line  736  and block  738  a determination is made as to whether the select switch  24  has been actuated. In the event that it has not, then the system dwells as represented at loop line  740  extending line  728 . Where the select switch  24  has been actuated, then as represented at line  742  and block  744  the maximum gripping force value which was selected is submitted to memory and, as represented at line  746  and block  748  the system provides a 1 step default value and a repetition of the step exercise is defaulted to a value of four. The program then continues as represented at line  750  wherein the system provides a prompt at readout  18  which displays the value of a selected maximum gripping force and further prompts the user that a default of 1 step is present and a default of four repetitions is present. The term “1 step” is intermittent or blinks as a part of this prompt to the user to elect the number of steps desired. This display is represented at block  752 . Then, as represented at lines  754  and block  756  the user or practitioner is permitted to adjust the number of steps within a range of 1 to 5 steps. As discussed above, this range is mandated within the system and the adjustment in the number of steps may be carried out by actuating menu switch  22 .  
         [0111]     The number of steps elected adjusts the percentage of maximum grip force factor in accordance with a preordained schedule. That schedule is provided in Table 2 below. For example, if only one step is elected, that target grip factor will be 20%. On the other hand if five steps are elected, the first trial will be at 100% of maximum grip force. The second step will be at 80% of maximum grip force and so forth. On the other hand, if four steps are elected, the initial trial will be in conjunction with an 80% maximum grip force factor; the second step will be at 60% and so forth as set forth in Table 2. For each of these percentages as set forth in Table 2, the corresponding hold on target or effort interval and rest intervals will follow the values given above in Table 1.  
                                                                           TABLE 2                                       No. of Steps Elected                1   2   3   4   5                        1 st  Step as % Max   20%   40%   60%   80%   100%        2 nd  Step as % Max       20%   40%   60%   80%       3 rd  Step as % Max           20%   40%   60%       4 th  Step as % Max               20%   40%       5 th  Step as % Max                   20%                  
 
         [0112]     The step value is elected by actuation of select switch  24  and the program continues as represented at line  758  and block  760 . Block  760  replicates a display at readout  18  which prompts the user by indicating that the maximum elected gripping force selected was 90 pounds and that A steps were selected and a further prompt is provided showing blinking or intermittent display of “4 REPS”. Then, as represented at line  762  and block  764  the operator may adjust the number of repetitions of the program to a value within a preordained number of 1 through 10 by actuating menu switch  22 . The elected number of repetitions then is selected by actuation of switch  24  and, as represented at line  766  and block  768  the system displays the now selected parameters of a maximum grip force, for example, 90 pounds, an election of A steps in the regimen and an election of “B” repetitions. Next, as represented at line  770  and block  772  the stepped exercise therapy is entered. Upon entry into this stepped exercise trial mode, target values are computed based upon the number of steps elected and the hold on target and rest intervals will be acquired, such data with respect to target factors being set forth in Table 2 and the latter hold on target and rest intervals being set forth in Table 1. This function is represented in block  776 . Line  778  reappears in  FIG. 17B  extending to block  780  which prompts the user with a display indicating that to start the step therapy the select switch  24  should be actuated. The operator may return the system to a previous menu at this juncture by actuating menu switch  22 . In this regard, as represented at line  782  and block  784  by actuating switch  22 , the program will again display that initially elected maximum 90 pound grip force along with the prompt to squeeze again or press select as represented at line  785  and node K. This returns the program to block  752  ( FIG. 17A ) where node K reappears at line  750 . While again actuating switch  22 , as represented at line  786  and block  788  a restarting of the step therapy test prompt is provided advising the user to actuate switch  24 . Again where switch  22  is actuated, then as represented at line  790  and block  792  the user is provided a prompt display at readout  18  advising that the previous menu may be elected by actuating select switch  24 . Where that switch is actuated, then as represented at line  794  and node H the program returns to block  712  as earlier described in connection with  FIG. 14A . In this regard, node H reappears in that figure in conjunction with line  796  extending to block  712 . Where menu switch  22  is actuated the program loops as represented at line  795  extending to line  782 .  
         [0113]     Returning to block  780 , where switch  24  has been actuated, then as represented at line  798  and block  800  the user is prompted to hold the grip force at the computed target level for 100%. Additionally, the prompt term “SQUEEZE” is provided within the readout  18 . Next, as represented at line  802  and block  804  a determination is made as to whether the grip force exerted by the user is within 10% of the computed target value. Where it is not, then the system dwells as represented at loop line  806  and the display represented at block  800  continues. Where the asserted grip force is within 10% of the target load, then as represented at line  808  and block  810  the mandated hold on target interval timeout set forth in Table 1 commences and, as represented at line  812  and block  814  a dynamic comparison value is derived for dynamic bar graph cueing. Next, as represented at line  814  and block  816  a computation then is made as to whether the instantaneous grip force is at or above 125% of the target value. Where that is the case, then as represented at line  820  and block  822  an audible warning cue is sounded. The program then continues as represented at lines  824  and  826  when the excessive force has been lessened. Line  826  is directed to block  828  which provides for carrying out a computation of a score value as a percentage of target for a sequence of time increments. Computation of this score has been discussed in connection with  FIG. 15 . The program then continues as represented at line  830 .  
         [0114]     Line  830  reappears in  FIG. 17C  extending to block  832  which provides a display at readout  18  with essentially instantaneous score values, the noted dynamic bar graph and hold time remaining for the initial step at hand. The dynamic bar graph has been described in conjunction with  FIGS. 16A-16E . Next, as represented at line  834  and block  836  a query is posed as to whether the hold time interval has expired. Where it has not, then the system dwells as represented at loop line  838  extending to node J. Node J reappears in  FIG. 17B  in conjunction with the line  840  extending to line  816 . However, where the hold on target interval has expired, then as represented at line  842  and block  844  an audible cue is generated and, as represented at line  846  and block  848  a Table 1 mandated rest interval is commenced. The program then continues as represented at line  850  and block  852  wherein the system cues the user that (A×B)−1 efforts remain out of the previously selected (A×B) efforts and further advises of the time remaining for the rest interval and the current score value. With this display, the system queries as to whether the rest interval has expired as represented at line  854  and block  856 . Where the rest time remains at hand, then the system dwells as represented at loop line  858  extending the line  850 . However, where the rest interval has expired, then as represented at line  860  and block  862  an audible cue is generated.  
         [0115]     Following the generation of this audible cue, as represented at line  870  and block  872  the program reiterates the trial sequence following the mandates of Tables 1 and 2 and the elected parameters. As represented at line  874  and block  876 , a query then is made as to whether the repetitions and associated efforts are complete. This value is the product of the elected number of steps A multiplied by the elected number of repetitions, B. Where that number of reiterations has not occurred, then the program continues as represented by look line  878  extending to line  870 . Where the number of repetitions is completed, then as represented at line  880  and block  882  a final score is computed and submitted to memory with calendar and force data. Next, as represented at line  884  and block  886  the program selects a message to the user which will be based upon the final score. For example, the user may be advised to consult a therapist or the program directions in the event of the low score and is congratulated in the event of a good score. As represented at line  888  and block  890  those messages are selected. Where the user actuates select switch  24 , the program continues as represented at line  892  and node H.  
         [0116]     Turning again to  FIG. 14A , node H reappears in conjunction with line  796  leading to the block  712  displaying a prompt that, to cause the program to enter the stepped therapy mode, the select switch  24  should be actuated. However, where menu switch  22  is actuated, then as represented at line  896  and block  898  the program displays a prompt that to enter the previous menu, the select switch  24  should be actuated. Where that select switch is so actuated, then as represented at line  900 , the program reverts to node E which reappears in the instant figure in conjunction with line  520  extending to block  522 . On the other hand, where the user actuates menu switch  22 , then as represented at line  902  the program reverts to node G. Node G is shown in the instant figure in conjunction with line  708  extending to block  526 .  
         [0117]     The user has the option of powering down instrument  10  by pressing select switch  24  for an interval of at least 2 seconds. This power off sequence is represented in the flow chart of  FIG. 18 . The sequence opens with node  910  and line  912  extending to block  914 . Block  914  indicates that select switch  24  is being actuated and held in an actuated state. During this actuated state, as represented at line  916  and block  918  a determination is made as to whether the 2 second interval has elapsed. If it has not, then as represented at line  920  and block  922  a query is posed as to whether the select switch  24  has been released before the termination of 2 seconds. If it has not, the system dwells as represented at loop line  924  extending to line  916 . Where the query at block  918  results in an affirmative determination, then as represented at line  926  and block  928  the instrument  10  is powered down. Where the determination at block  922  indicates that the switch  24  has been released prior to the elapsing of 2 seconds, then as represented at line  930  and block  932  the program reverts to the previous or last display which was published at readout  18 .  
         [0118]     The protocol based isometric exercise approach of the invention has applicability to a broad range of muscle groups of the user. By employing the protocol which, inter alia, involves the evaluation of maximum muscle group strength as a precondition to then applying a factor related protocol, one of those factors may apply to the measured maximum strength value. The remaining factors which involve, for example, variations of target loads, hold times , rest intervals and exercise regimen planning in terms of calendar days achieves a safe and effective utilization of isometric activities. The exercisable anatomical features to be strengthened are generally identifiable as muscle groups of the human anatomy which may include but are not limited : jaw muscles, neck muscles, shoulder muscles, upper arm muscles, lower arm muscles, hand muscles, finger muscles, diaphragm muscles, abdominal muscles, lower back muscles, upper leg muscles, lower leg muscles, ankle muscles, foot muscles, and tow muscles.  
         [0119]     Looking to  FIG. 19 , a flow diagram is presented which outlines the methodology achieving this safe utilization of isometric exercises. In the figure, block  950  reveals that the user or therapist may establish a goal of strength for the muscle group involved. This may be achieved by measuring the maximum strength of an unimpaired contralateral muscle group. For example, a left arm or upper leg muscle group may be tested to determine a strength goad for a right arm or right upper leg muscle. Where no unimpaired contralateral muscle group is available to set this goal strength, a medical professional will establish an appropriate goal strength. The method continues as represented at line  952  of block  954  providing for the measurement of maximum strength of the specific anatomical feature to be treated. As represented at line  956  and block  958 , the methodology identifies a protocol matrix of factors. In this regard, a strengthening protocol is derived which is based upon timed efforts which are equal to a percentage of the measured maximum strength as derived in connection with block  954 . The matrix of factors further include hold times at a factor or factors of the measured maximum strength, the repetition of these efforts for a given trial or exercise session and the duration of rest periods where repetitions are involved. Such protocol further will indicate the intervals of repetitions of the exercise sessions themselves during a stated period of time in hours, days, weeks, months and the like. This matrix of factors may be contained, for example, in computer memory. Looking to line  960  and block  962 , the procedure next nominates values to the factors provided in conjunction with block  958 . In this regard, the strengthening protocol which is developed utilizes nominated factors from the matrix of these exercise factors. In effect, the nominated factors may be identified as “effort” applied by the specific anatomical feature and the effort time period during which the effort is to be applied such that there is a relationship among the percentage of the measured maximum strength of time wherein the higher the percentage, the shorter the effort time and the number of repetitions of these efforts during an exercise session, the rest period time between cessation of one effort and the beginning of the next succeeding effort such that there is a relationship between the percentage of the measured maximum strength and the rest time wherein the higher the percentage the longer the rest time and the number of exercise sessions in a given time period (hours, days, weeks, months). As represented at line  964  and block  966 , the procedure initiates and monitors the exercise protocol with nominated factors. In this regard, the procedure monitors and guides the exercise effort to be applied and while being applied, provides visual and/or audible cues to encourage compliance to the elected protocol using symbols as the visual cues and words which clearly guide the effort to be applied. While that effort is being applied, using audible cues and words which assist to properly perform the effort, rest periods and repetitions for each exercise session. Looking to line  968  of block  970 , the method provides for annunciating an alarm when an exercise effort level is exceeded. In this regard, an audible alarm is produced if the exercise effort exceeds a predetermined or factor determined level beyond which it is considered that the exercise effort could be damaging to the human physiology or the specific anatomical feature at hand. As represented at line  972  and block  974  the method provides compliance scores in real-time and in summation during the course of an exercise effort and subsequent thereto. As described herein, the program calculates a compliance score during each exercise effort in percent of that effort required in the strengthening protocol and provides this compliance score in real-time as the effort is being accomplished on the specific anatomical feature. An averaging of this compliance score over each exercise effort time period is devised to depict the degree to which the exercise effort applied has been accomplished. By accumulating the compliance scores during each rest period and then presenting a final compliance score issued in the form of both a number as a percent accomplished and in an instruction set an indication is derived as to how well the exercise protocol was performed or how to improve future compliance. Next, as represented at line  976  at block  978  the exercise data is archived for review and potential transfer to a remote interactive entity. This step in the procedure accumulates real-time and summary data for each effort or trial and the specific protocol being utilized. It may be noted that these protocols are selected each time the exercisable anatomical feature is elected to be strengthened such that the elected protocol, the effort being applied and the compliance being calculated during and at the conclusion of each effort may be reviewed remotely as it is being accomplished using suitable data communication assistance and at the conclusion of each effort. The archive data is time-stamped and uniquely identified for retrieval.  
         [0120]     Through use of the invention, cardiac function and a variety of physiologic effects are produced, including effects on the endothelium and the release of biological active signaling molecules, including nitric oxide. The following two studies demonstrate the measureable biochemical and biophysical effect of utilization of the system, method, and apparatus of the invention.  
         [0121]     Among many other factors, both hypertension and arterial distensibility are independent risk factors for cardiovascular disease. The research of Wiley et al. (1992) and Taylor et al. (2003) demonstrated that isometric training is effective for reducing resting blood pressure (RBP). NO is a potent vasodilator, and crucial component of the regulation of vascular tension (See  FIG. 20 ), thus, isometric exercise is expected to affect NO production and bioavailability.  
         [0122]     As NO is a rapidly diffusible gas, release of NO in the blood vessels of the arms or other muscle groups, in response to isometric training is expected to have both a local and systemic effect on vasodilation, arterial distensibiltiy and resting blood pressure. Thus an increase of arterial distensibility in response to isometric exercise may contribute to reduction in RBP and increased NO bioavailability. A wide variety of muscle groups such as from exercisable regions of the musculature of the user including jaw muscles, neck muscles, shoulder muscles, upper arm muscles, lower arm muscles, hand muscles, finger muscles, diaphragm muscles, abdominal muscles, lower back muscles, upper leg muscles, lower leg muscles, ankle muscles, foot muscles, and toe muscles may provide a therapeutic benefit by utilization of the isometric exercise protocols of the invention.  
         [0123]     To demonstrate the systemic effect of practicing the system and method off the invention, the impact of isometric arm and leg exercise on RBP and central and peripheral arterial distensibility was tested in patients being medicated for hypertension. Resting blood pressure was measured by brachial oscillometry, and arterial distensibility, as measured by Doppler ultrasound and applanation tonometry in the carotid, brachial and femoral arteries. Study participants were directed to perform isometric handgrip (IHG) exercise (n=10), or isometric leg press (ILP) exercise (n=6) according to the method of the invention three times per week for eight weeks. Exercise intensity was maintained at 30% of maximal voluntary contraction.  
         [0124]     Following eight weeks of IHG exercise, systolic blood pressure decreased significantly (from 140.2 mmHg+/−3.82 to 132.3 mmHg+/−3.97), while no decrease was observed after isometric leg press exercise. Diastolic blood pressure did not change after either IHG or ILP exercise. Measurement of carotid arterial distensibility showed a significant improvement following IHG exercise (from 0.1105 mmHg−/−1×10 −2  0.0093 to 0.1669 mmHg+/− 1 × 10   −2  0.0221), while no such changes occurred in the ILP exercise group. Peripheral arterial distensibility did not change following either IHG or ILP exercise. These studies demonstrate that the isometric handgrip exercise according to the invention improves resting systolic blood pressure and carotid arterial distensibility. As arterial tension is under the direct control of the NO/LDL-cholesterol signaling system, the system and method of the invention allows modulation of NO and indirectly of the LDL-cholesterol components.  
         [0125]     As described previously, hypertension is associated with endothelial dysfunction, reduced NO bioavailability, and the development of coronary artery disease among other effects on the body of the patient. The isometric hand grip exercise protocol of the invention further reduces blood pressure even in patients already medicated for hypertension. In order to demonstrate the mechanisms of IHG affect on hypertension, endothelial function was studied in patients practicing the system and method of the invention. Study participants (n=8, 62+/−3.5 years) performed 4 sets of 2-minute isometric contractions at 30% of their maximal voluntary contraction. Ulnar reactivity was assessed in alternate hands, 3×/week for 8 weeks. Resting blood pressure was measured using automated brachial oscillometry. Vascular reactivity was measured in both arms using ultrasound imaging to determine brachial artery flow-mediated dilation (FMD). Following utilization of the IHG protocol of the invention, systolic blood pressure decreased (137 mm Hg+/−5.3 to 121.7 mm Hg=/−4.8 mmHg, p=0.03). Relative FMD increased (1.6%+/−0.3 to 4.5%+/−0.5 and normalized to average shear rate, 0.007%+/−0.001 to 0.02+/−0.004%/s−1). Reactive hyperemic flow decreased (peak, 344.3+/−36.5 to 258.2+/−27.2 ml/min and average, 301.6+/−33.1 to 239.0+/−28.4 ml/min). Average resting blood vessel diameter and resting flow rates remained unchanged. As systemic shear stress is known to induce the activity of NO as a vasodilator, the IHG training apparently causes the release of NO, as shown by an increase in flow mediated arterial dilation. The IHG exercise protocol produced a reduced reactive hyperemic flow, accompanied by improvements in normalized FMD, and a heightened vasoreactive sensitivity to the reactive hyperemic stimulus. The IHG protocol by providing an improved cardiovascular function, demonstrates a modification of the wall shear stress setpoint for the activation of eNOS to produce biologically active levels of NO.  
         [0126]     The statin class of drugs used in the treatment of hypercholesterolemia surprisingly has a pleiotropic effect on a variety of other systems of the body, including on the bioavailability of NO. Thus, by down modulating cholesterol biosynthesis, statin drugs affect systems that are controlled by NO dependent signaling systems. The method and apparatus of the invention, surprisingly, by stimulating changes in the structure of the vasculature, and by creating increased wall shear stress in the blood vessels experiencing the effects of the inventive protocol also induces broad effects on signaling systems including those that regulate the bioavailability of NO and serum cholesterol and LDL-cholesterol levels.  
         [0127]     Since certain changes may be made in the above-described apparatus, method and system without departing from the scope of the invention herein involved, it is intended that all matter contained in the description thereof or shown in the accompanying drawings shall be interpreted as illustrative and not in a limiting sense.