Abstract:
The present invention integrates an actuated tilting rehabilitation table, video tracking of the patient arm and opposite shoulder, a low-friction forearm support with grasping force sensing, remote data transmission and additional weighing means, one or more large displays, a computer and a plurality of simulation exercises, such as video games. The patient can be monitored by a local or remote clinician. The table tilts in order to increase exercise difficulty due to gravity loading on the patients arm and shoulder. In one embodiment, the present the invention includes an actuated tilting table which tilts in four degrees of freedom.

Description:
CROSS REFERENCE TO RELATED APPLICATION 
       [0001]    This application claims the benefit of U.S. Provisional Patent Application No. 60/964,861 filed Aug. 15, 2007, the entirety of which is hereby incorporated by reference into this application. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    1. Field of the Invention 
         [0003]    The present invention is a device, system and method for providing rehabilitation to several types of patients in a rehabilitation hospital or outpatient clinic. The approach integrates an actuated tilting rehabilitation table, video tracking of the patient&#39;s arm and opposite shoulder, a low-friction forearm support with grasping force sensing, remote data transmission and additional weighing means, one or more large displays, a computer and a plurality of video games. 
         [0004]    2. Description of Related Art 
         [0005]    A training system for arm rehabilitation is described in Yu-Luen Chen et al, “Aid Training System for Upper Extremity Rehabilitation,” 2001 Proceedings of the EMBS International Conference, Istanbul, Turkey. Patients exercise on a special table that incorporates reed relays and a hand support (“arm skate”) with small underside wheels. The movement of the arm in the arm skate on the supporting table is detected by the interaction of the magnet incorporated in the arm skate with the relays integrated in the table. A computer presents a variety of patterns on its monitor, which the patient needs to replicate to improve arm coordination, with performance data stored by the computer in a clinical database. The table is horizontal and does not use virtual reality simulations. 
         [0006]    Another training system that uses a forearm support on a table for rehabilitation purposes is described by some of the inventors of the present specification in Kutuva et al., “The Rutgers Arm: An Upper-Extremity Rehabilitation System in Virtual Reality,” Proceedings of the Fourth International Workshop on Virtual Rehabilitation (IWVR&#39;05), pp. 94-103, Catalina Island, Calif., September 2005. The table has a low-friction surface and a forearm support has a low-friction underside (made of TEFLON®studs). The tracking of the forearm movement is done by a magnetic tracker (Fastrack, Polhemus Inc.), with a sensor mounted on the forearm support, and an emitter mounted on the table away from the patient. Patients exercise sitting at the table and looking at a computer monitor, while playing a plurality of virtual reality games. The games are designed to improve motor coordination, as well as dynamic arm response. The table does not tilt. 
         [0007]    Several tilting tables exist commercially and are used in rehabilitation. They are meant for people who have low blood pressure and who get dizzy when they stand up. Tilting tables are also used for the rehabilitation of patients who have to lie down for a long period of time. The person lies face up on a padded table with a footboard and is held in place with a safety belt. The table is tilted so that the angle is very slowly increased until the person is nearly upright. By slowly increasing the angle, the patients blood vessels regain the ability to constrict. 
         [0008]    A study describes development of a sensorized tilt table which measures and displays the knee bent angle and pressure for each foot during exercise in real time, as described in Kimet et al. “An Intelligent Tilt Table for Paralytic Patients,” 3 rd  Kuala Lumpur International Conference on Biomedical Engineering, Kuala Lumpur, Malaysia, 2006. It is expected that the patient&#39;s exercising effect can increase by monitoring these two values during exercise. Tilt tables are known for providing tilting manually or using an electrical motor, such as in a Rehab Electric Tilt Table manufactured by Cardon Rehab. 
         [0009]    An automated stepping training developed with the tilting table is described in Colombo et al. “Novel Stepping Mechanism: Design Principles and Clinical Application,” Rehabilitation Robotics, ICORR 2005. Unlike the previous tilting tables it exercises the feet in stepping. No virtual reality simulation is incorporated and tilting is done manually, rather than determined by a simulation. 
         [0010]    All of the above tilting-table based systems are for rehabilitation of the legs. The tilting tables described above do not incorporate virtual reality simulations and do not store/upload clinical data automatically. They have a single degree of freedom (the tilting angle). 
         [0011]    Systems for rehabilitating the arms are known, and are based on force feedback joysticks (such as those manufactured by Logitech or Microsoft), or various types of planar or 3D robots. Examples of planar robots are the MIT Manus or those described in Colombo et al., “Upper Limb Rehabilitation and Evaluation of Stroke Patients Using Robot-Aided Techniques”, Rehabilitation Robotics, 515-518 (2005). Other examples of 3D robots are the Reo robot manufactured by Motorika, N.J., or the Haptic Master manufactured by FCS, Holland. 
         [0012]    Other upper limb rehabilitation systems have been described. U.S. Pat. No. 7,204,814 describes an orthotic system that performs predefined or user-controlled limb movements, collects data regarding the limb movement, performs data analysis and displays the data results, modifies operational parameters based on the data to optimize the rehabilitative process performed by the system. A force sensor data, torque data and angular velocity data can be collected using an external actuating device. 
         [0013]    U.S. Patent Application Publication No. 2007/0060445 describes a method and apparatus for upper limb rehabilitation training of coordinated arm/forearm, forearm/forearm, and grasping movements comprising a non-robotic, passive support, an arm/forearm sensor, gripping device and sensor. A computer processes measurements of movements to control a graphical representation of the arm/forearm and grasping movements in interaction with a virtual environment. 
         [0014]    It is desirable to provide a device, system and method for rehabilitation of an upper limb in which an activated tilting table provides a plurality of degrees of freedom and grasping force is sensing integrated into a video tracking system. 
       SUMMARY OF THE INVENTION 
       [0015]    The present invention integrates an actuated tilting rehabilitation table, video tracking of the patient arm and shoulder, a low-friction forearm support with grasping force sensing, remote data transmission and additional weighing means, one or more large displays, a computer and a plurality of simulation exercises, such as video games. The patient can be monitored by a local or remote clinician. Online storage of data obtained by the rehabilitation tilting table can be provided. Additionally, the table surface can be constructed as a graphics display making a separate display unnecessary. 
         [0016]    In one embodiment, a patients arm rests on a forearm support that has infrared LEDs. The patient wears similar LEDs on the opposite shoulder, and an infrared video camera is used to track the patients arm movement on the table. The table tilts in order to increase exercise difficulty due to gravity loading on the patients arm. In one embodiment, the present the invention includes an actuated tilting table which tilts in four degrees of freedom. A large display, facing the patient presents a sequence of rehabilitation games with which the patient interacts by moving the arm resting on the low-friction support, on the table surface. 
         [0017]    The invention will be more fully described by reference to the following drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0018]      FIG. 1  is a schematic diagram of a tilting rehabilitation table system being used by a patient. 
           [0019]      FIG. 2  is a schematic diagram of the tilting rehabilitation table system. 
           [0020]      FIG. 3  is a schematic diagram in which a top surface of the tilting table is provided at an increased angle from the patient. 
           [0021]      FIG. 4  is a schematic diagram in which the top surface of the tilting table is provided at an increased right angle from the patient. 
           [0022]      FIG. 5  is a schematic diagram of actuators of the tilting rehabilitation table system used with the tilting table. 
           [0023]      FIG. 6  is a detailed view of a top joint assembly connecting an actuator shaft to the top surface of the tilting table. 
           [0024]      FIG. 7  is a detailed view of a bottom joint assembly connecting an actuator shaft to the bottom surface of the tilting table. 
           [0025]      FIG. 8  is a side elevation view of patient wearing the forearm support assembly used in the tilting rehabilitation table system. 
           [0026]      FIG. 9  is a schematic diagram of an underside of a forearm support assembly of the tilting rehabilitation table. 
           [0027]      FIG. 10  is a view of the patient wearing a shoulder harness assembly used in the tilting rehabilitation table system. 
           [0028]      FIG. 11  is a schematic diagram of an alternate embodiment of the tilting table. 
           [0029]      FIG. 12  is a schematic diagram of an alternate embodiment of the tilting table where top surface is a display. 
           [0030]      FIG. 13  is a system block diagram for the tilting rehabilitation table system. 
           [0031]      FIG. 14  is a schematic diagram of a patient baseline screen displayed by the tilting rehabilitation table system. 
           [0032]      FIG. 15A  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
           [0033]      FIG. 15B  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
           [0034]      FIG. 15C  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
           [0035]      FIG. 16A  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
           [0036]      FIG. 16B  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
           [0037]      FIG. 17  is a schematic diagram of a virtual scene displayed by the tilting rehabilitation table system. 
       
    
    
     DETAILED DESCRIPTION 
       [0038]    Reference will now be made in greater detail to a preferred embodiment of the invention, an example of which is illustrated in the accompanying drawings. Whenever possible, the same reference numerals will be used throughout the drawings and the description to refer to the same or like parts. 
         [0039]      FIGS. 1 and 2  illustrate tilting rehabilitation table system  1 . Tilting rehabilitation table system  1  incorporates tilting table  2  which has top surface  3  and underside surface  4 . Top surface  3  can be a U-shaped, symmetrical, low-friction surface. Underside surface  4  can have a U-shape. For example, low top surface  3  can be made of carbon fiber, or other durable and light material, covered by a low-friction coating. Suitable low-friction coatings include TEFLON® sheets. Underside walls  14  extend upwardly from underside surface  4 . 
         [0040]    Patient  5  sits in chair  6  and rests arm  7  to be rehabilitated in low-friction forearm support  25 . Patient  5  exercises while watching display  8  placed at the opposite side of tilting table  2 . Preferably, display  8  is a large display having dimensions of at least about 9 ft by 6 ft. Video camera  9  is attached to vertical support  10 . Vertical support  10  can be U-shaped and rigid. Vertical support  10  extends from and is attached to top surface  3 . This arrangement allows video camera  9  to view tilting table  2  and patient  5  simultaneously. Video camera  9  can be a conventional digital camera. Infrared filter  11  can be attached to lens  12  of video camera  9 . LEDs  13  are mounted at the corners of top surface  3  and can be wired to direct current source (not shown). For example, three LEDs can be used for providing calibration of video camera  9 . Vertical support  10  is mounted to top surface  3  such that it keeps the same relative orientation regardless of tilt angle  15  of top surface  3 , thereby making re-calibration of video camera  9  unnecessary once tilt angle  15  changes during a rehabilitation session. 
         [0041]    Computer  16  renders exercise simulation  17  and displays them on display  8 . For example, exercise simulation  17  can be an animated or virtual reality sequence. Computer  16  is preferably a multi-core PC workstation. Computer  16  also receives input from video camera  9 . Computer  16  runs tracking software  18  and communicates with controller  19 . Controller  19  activates actuators  20  to provide tilt of top surface  3 . Computer  16  is connected to Internet  66  and transparently uploads clinical data  67  to remote clinical database server  68 . Remote computer  181  connected to clinical database server  68  over Internet  66  is used to execute remote graphing software  180 . 
         [0042]      FIG. 3  shows the orientation of top surface  3  and camera support  10  when tilt angle  15  is increased to move the angle away from patient  5 . Increased tilt angle  15  makes in/out movements of arm  7  more difficult. 
         [0043]      FIG. 4  shows a different tilt of top surface  3 , in which tilt angle  15  is to the right of patient  5 . This tilt angle makes arm movements from left-to-right more difficult than those when top surface  3  is horizontal. Other tilt angles  15  can be used when the left side of top surface  3  is tilted up or when the side closer to patient  5  is tilted up. These make more difficult corresponding arm  7  movements, such as right-left or out-in, respectively. In one embodiment, top surface  3  can be tilted in four degrees of freedom. 
         [0044]    Tilt angle  15  is produced by two or more actuators  20  placed under top surface  3 , as shown in  FIG. 5 . Actuators  20  are preferably linear electrical actuators. Actuators  20  are positioned under top surface  3 . Each actuator  20  includes base  21  and translating shaft  22 . Translating shaft  22  is connected to top surface  3  by top joint assembly  23 . Base  21  is connected to underside walls  14  with bottom joint assembly  30 . Actuators  20  are controlled by controller  19 . Controller  19  can be a multi-channel micro-controller such as those which are available commercially. Controller  19  in turn receives commands from computer  16  running exercise simulation  17 . In one embodiment, five actuators  20  can be used and the amount of translation of actuator shaft  22  provides tilt angle  15  which can be varied from about 0 degrees (horizontal) to about 30 degrees. The more top surface  3  is tilted, the larger the effect gravity has due to the weight of arm  7  of patient  5  and of forearm support  25  and the harder exercise simulation  17  is to perform. 
         [0045]      FIG. 6  shows a detailed view of top joint assembly  23  which connects actuator shaft  22  to the underside of top surface  3 . Top joint assembly  23  has horizontal rotating joint  26  and vertical rotating joint  27  which together produce two degrees of freedom for top joint assembly  23 . The axis of rotation of horizontal rotating joint  26  is perpendicular to the axis of rotation of vertical rotating joint  27 . Horizontal rotating joint  26  is attached to the underside of top surface  3  using plate  28  and bolts  29 . 
         [0046]      FIG. 7  shows a detailed view of bottom joint assembly  30 , which connects base  21  to the inner side of underside walls  14 . Bottom joint assembly  30  has horizontal rotating joint  31  and vertical rotating joint  32  which together produce two degrees of freedom for bottom joint assembly  30 . The axis of rotation of horizontal rotating joint  31  is perpendicular to the axis of rotation of vertical rotating joint  32 . Vertical rotating joint  32  is attached to the inner side of underside walls  14  through plate  33  and bolts  34 . 
         [0047]    A side view of the patient  5  sitting in chair  6  and using of forearm support assembly  25  used by patient  5  is shown in  FIG. 8 . Forearm  7  and wrist  35  of patient  5  are secured to forearm support base  36  using a plurality of straps  37 . For example, straps  37  can be formed of a hook and loop material of VELCRO®. Forearm support base  36  can be made of a lightweight material such as plastic, and is hollow. Pressure sensor  41  measures the air pressure inside hollow compliant element  44 . A suitable hollow compliant element  44  can be a rubber ball. Grasping forces  45  exercised by fingers  46  of patient  5  are measured. Video camera  9  shown in  FIG. 1  views LED assembly  42  which is formed of two infrared LEDs  50  mounted on plastic support  51  for providing data on arm movements and rotation. LED assembly  42  in turn is mounted on movable assembly  52 . Movable assembly  52  rotates on hinges  53  attached to forearm support base  36 . Movable assembly  52  rotates open to allow forearm  7  to be placed on forearm support top surface  54 . Forearm support top surface  54  is preferably made of a compliant material (such as plastic foam), for increased comfort. Forearm support base  36  has chambers  39 ,  76  and  77 . Chamber  39  can be used to incorporate electronics assembly  40  to which is connected pressure sensor  41 . Output of pressure sensor  41  is processed by electronics assembly  40 . Electronics assembly  40  includes an analog-to-digital converter  47  and wireless transmitter  48 . Transmitter  48  can be a conventional wireless Bluetooth® type transmitter. Transmitter  48  communicates with receiver  49  incorporated in computer  16 , as shown in  FIG. 2 . Computer  16  can change exercise simulation  17  according to grasping forces  45  of patient  5 . Computer  16  can also change exercise simulation  17  based on forearm  7  position/orientation given by video camera  9 . For example, exercise simulation  17  can be rehabilitation games. LED assembly  42  and electronics assembly  40  are connected to battery  43  in chamber  77 . Chamber  76  of base  36  can be used to allow the addition of modular weights  56 . The addition of modular weights  56  to forearm support base  36  allows an increased difficulty of exercise simulation  17 . The difficulty of performing exercise simulation  17  is increased with the increase in modular weights  56 , with the increase in tilting angle  15 , and with the number and level of exercise simulation  17 . 
         [0048]      FIG. 9  is a view of the underside of the forearm support assembly  25 . Underside surface  38  of forearm support  25  has a plurality of low friction studs  55 . Low friction studs  55  are preferably made of TEFLON®. 
         [0049]      FIG. 10  shows shoulder harness assembly  57  worn by patient  5  on shoulder  58  opposite to arm  7  being rehabilitated. Shoulder harness assembly  57  incorporates shoulder LED  59  wired to battery  60 . Shoulder LED  59  is an infrared LED for providing data on compensatory movements of patient  5 . Harness assembly  57  is formed of adjustable segments  61 . Segments  61  are preferably formed of a hook and loop material, such as VELCRO®. Video camera  9  takes images of shoulder LED  59 . Tracking software  18  running on computer  16  determines when patient  5  is doing undesirable compensatory leaning movements. Tracking software  18  can be adjusted by a therapist to be more sensitive, or less sensitive to leaning of patient  5 . 
         [0050]      FIG. 11  illustrates an alternate embodiment of tilting table  62  for use with two forearm supports  25 . Top surface  3  has a U-shape cutout  63  allowing patient  5  to be seated centrally to table axis  64 . Patient  5  moves two arms  7  while supported by two low-friction forearm support assemblies  25 . This allows training of both arms simultaneously, with benefits to recovery of patient  5 . In one embodiment, patient  5  also wears one shoulder harness  57 , as it is sufficient to detect the leaning of the shoulder opposite to the disabled arm  7 . Video camera  9  views LEDs  42  on both forearm support assemblies  25 , as well as LEDs  59  on one shoulder harness assembly  57 . Forearm support assembly  25  is modified such that the number of infrared LEDs  42  differs between the two forearm support assemblies  25 . For example three LEDs  42  will be on the left-arm forearm support  73 , while the right-arm support  71  still has two LEDs  42  as previously described in  FIG. 8 . This allows tracking software  18  to differentiate between left arm and right arm movements. Tracking software  18  tracks two arms  7  in real time. Data from tracking software  18  is used by computer  16  to run two-arm exercise simulation  17 . In this embodiment, the same type of actuators  20  as shown in  FIG. 5 , can be used in this embodiment. Preferably, four actuators  20  are used in this embodiment. 
         [0051]      FIG. 12  illustrates an alternate embodiment of tilting table  2 . In this embodiment, top surface  3  is also display  69 . For example, display  69  can be similar to commercially available thin organic LED (OLED) displays. In this embodiment, the tracking of forearm  7  may be performed by infrared camera  9 , or through a touch-sensitive layer  70  incorporated in display  69 . In this case the display  69  is a touch sensitive screen such as those available commercially. In case overhead camera  9  is used, forearm support assembly  25  is modified as shown in  FIG. 11 . Actuator assembly  20  can be connected to frame  72  bordering display  69  and to supporting surface  4 . A low-friction transparent film  75  can be retrofitted to display  69 , to prevent scratching by the forearm support assemblies  71  and  73  that sit on it. 
         [0052]    A system block diagram for the tilting rehabilitation table system  1  is illustrated in  FIG. 13 . Each rehabilitation session starts with session start block  78 . Session start block  78  loads the patient&#39;s ID and other clinical data  67  for arm  7  to be rehabilitated. Session start block  78  transfers control to the session scheduler block  79  which sets the structure of a rehabilitation session, for example, number, type and order of exercises, as well as the difficulty level settings. Session scheduler block  79  is structured such that it applies a customized treatment depending on progress of patient  5  (the order of the particular session being done out of the prescribed number of sessions). Session scheduler block  79  begins by starting session baseline  80  which measures the performance of patient  5  in that day. Session baseline  80  is stored transparently by clinical database server  68  and can be used to track progress of patient  5  over the sequence of rehabilitation sessions. Patient  5  progress can be graphed using remote graphing application  180  running on remote computer  181 . It is envisioned that remote computer  181  communicates with clinical database server over Internet  66 . Session baseline  80  is also used to fine-tune the “gains” of exercise simulation blocks  81 ,  82  and  83 , such that in virtual reality movements are amplified and success assured even for very limited real arm  7  movements. Exercise simulation blocks  81 ,  82  and  83  can perform exercise simulation  17 . Intelligent agent block  84  monitors the patient progress and can automatically vary tilt angle  15  to assist/resist movement. Intelligent agent block  84  can control actuators  20  through their controller  19  connected to computer  16  running exercise simulation blocks  81 ,  82  and  83 . Actuators  20  provide data to exercise simulation blocks  81 ,  82  and  83  such that virtual table (not shown) in the scene mimics tilt of tilting table  2 . Video camera  9  detects the position of LEDs  50  at the top of forearm support assembly  25  and sends the information to tracking software  18  run by computer  16 . Tracking software  18  extracts arm position information and body leaning information and transmits this data to exercise simulation blocks  81 ,  82  and  83 . This data is then used to animate in real time an avatar of the patient&#39;s hand(s) (not shown). Manual emergency switch  85 , when pressed by attending therapist and/or patient  5  triggers an end to the rehabilitation session through software block  86 . 
         [0053]      FIG. 14  illustrates an example of patient baseline screen  87  displayed in display  8  or on display  69 . Patient  5  is asked to move the arm  7  in large circles to color virtual representation  88  of the rehabilitation table surface  3 . The surface of colored area  89  increases with the movement of virtual sphere  90  which responds to the movements of forearm support assembly  25 . Size and shape of colored area  89  are a measure of the ability of patient  5  that day. Extent of movement  91  in the left/right (horizontal) direction and extent of movement  92  in the in/out direction are used to adjust the rehabilitation exercise simulation blocks  81 ,  82  and  83 . Baseline screen  87  also shows tilt angle  15  at which baseline  80  was taken. 
         [0054]      FIG. 15A  shows an embodiment of rehabilitation exercise simulation block  81  with a virtual world representation having tilted table avatar  88 . Virtual sphere  94  is shown on table surface  93  together with a virtual target rectangle  95 . An ideal path between virtual sphere  94  and virtual target rectangle  95  is visualized by path shown as dotted line  96 . The placement of virtual target rectangle  95  and virtual sphere  94  on table surface  88  is such that it requires patient  5  to move arm  7  close to extent of movement  91  and extent of movement  92  of baseline  87 . Patient  5  is asked to pick up virtual sphere  94  with a semi-transparent hand avatar  98  and place it in virtual target rectangle area  95 . In order to grasp virtual sphere  94 , transparent hand avatar  98  has to overlap virtual sphere  94  and patient  5  squeezes compliant element  44  on forearm support assembly  25 , as shown in  FIG. 1 . Real movement of patient  5  is tracked by video camera  9  and computer  16  shows a corresponding trace  97  on table surface  88 . 
         [0055]      FIG. 15B  shows an alternate embodiment of exercise simulation block  81  of the pick-and-place exercise in which ideal path  96  shown as a straight dotted line. This corresponds to in/out movements of arm  7 . This process is repeated a number of times, with the trial (repetition) number  190  and the total arm movement (endurance)  191  corresponding to these repetitions being displayed in simulation  81 . Other placements of virtual target rectangle  95  and virtual sphere  94  can be used with corresponding ideal path specifications  96 . The difficulty exercise simulation block  81  such as a pick-and-place exercise, is varied by making virtual target rectangle  95  smaller and by requiring patient  5  to make more pick-and-place movements. For patient  5  capable of exerting finger forces  45 , difficulty is further increased by elevating the threshold of finger grasping forces  45  detected by the forearm assembly  25  in  FIG. 8  at which level corresponding hand avatar  98  can capture virtual sphere  94 . 
         [0056]      FIG. 15C  shows bundle of traces  99  displayed by exercise simulation block  81  at the end of exercises after a number of pick-and-place movements were completed. In this embodiment, bundle of traces  99  corresponds to repeated pick-and-place movements of arm  7  in the left-right-left direction. The tightness of bundle of traces  99  is indicative of the motor control abilities that day for patient  5 . 
         [0057]      FIG. 16A  shows an embodiment of exercise simulation block  82  referred to “Breakout 3D”. This exercise depicts ball  100 , paddle  101 , and array of cubes  102 , all located on play board  103 . Paddle  101  is used to bounce ball  100  towards cubes  102  with one cube being destroyed for each bounce of ball  100  off of paddle  101 . Ball  100  can bounce off of three sides  104  of play board  103 , or off multiple cubes  102 , but is lost if it misses paddle  101 . In an alternate embodiment, paddle  101  can move mostly left-right, within the lower portion of play board  103 , delineated by dashed line  105 . The difficulty of exercise simulation block  82  is set by the number of available balls  100 , the speed of balls  100 , and the size of paddle  101 . The higher the speed of ball  100 , the smaller the size of paddle  101 , and the fewer the number of available balls  100 , the harder the Breakout 3D of exercise simulation block  82  game is. The goal of the Breakout 3D exercise simulation block  82  is to destroy all cubes  102  with the available number of balls  100 . The Breakout 3D of exercise simulation block  82  is designed to improve hand-eye coordination and cognitive anticipatory strategies of patient  5 . 
         [0058]      FIG. 16B  is another embodiment of the Breakout 3D of exercise simulation block  82 , in which board  103  is rotated to show array of cubes  102  to one side of the scene. In this example paddle  101  moves mostly vertically in the scene, within the area to the right of dotted line  105 , requiring corresponding in-out-in movements of arm  7 . 
         [0059]      FIG. 17  is an embodiment of exercise simulation block  83  called “Treasure Hunt”. The scene depicts deserted island  106  with line of stones  107  on top of virtual sand  108 . The shape of line of stones  107  replicates the shape of baseline surface colored area  89 . There are a number of virtual treasures chests  109  inside sand  108  surrounded by line of stones  107 . Patient  5  controls virtual shovel  110  with which to remove sand  108  covering treasure chests  109 . Every time a new treasure chest  109  is found score  111  displayed in the scene is increased. In order to find a new treasure chest  109  shovel  110  has to be moved in sand  108  that overlaps treasure chest  109 . If tracking software  18  detects leaning of patient  5  treasure chest  109  is not revealed even if shovel  110  is in the correct position and score  111  is not increased. At higher level of difficulty, a sand storm occurs. Part of the already uncovered treasure chests  109  are covered again by sand  108  requiring more movement of arm  7  of patient  5  arm  7  to uncover treasure chest  109  again. The Treasure Hunt exercise simulation block  83  is timed and remaining time  112  is displayed at the top of the scene. Patient  5  attempts to uncover all of treasure chests  109  in the allowed amount of time  112 . This exercise is aimed at increasing arm endurance of patient  5 . In other embodiments, other simulation exercises can be played by patient  5 . 
         [0060]    It is to be understood that the above-described embodiments are illustrative of only a few of the many possible specific embodiments, which can represent applications of the principles of the invention. Numerous and varied other arrangements can be readily devised in accordance with these principles by those skilled in the art without departing from the spirit and scope of the invention.