On Effective Movement in CPM for Shoulder Joint
Shota MIYAGUCHI, Kousei NOJIRI, Nobutomo MATSUNAGA, and Shigeyasu KAWAJI
∗ Graduate School of Science and Technology, Kumamoto University
2-39-1 Kurokami, Kumamoto 860-8555, Japan
miyaguchi@actrl.cs.kumamoto-u.ac.jp
Abstract—Continuous passive motion (CPM) is an orthopedic
treatment or physiotherapy method that promotes recovery of
impaired joints, and is tried to apply for treatment of the shoulder
joint disorders. The shoulder joint has a complex structure, where
the inner/outer rotation torque of the shoulder joint varies due
to ad-/abduction angle. Wrong ad-/abduction angle causes the
excessive inner/outer rotation torque of the shoulder joint, and
aggravates joint disorders. So, it is required to adjust suitably
the ad-/abduction angle to suppress the inner/outer rotation
torque. In this paper, the ad-/abduction motion that suppresses
the inner/outer rotation torque is clarified. The variation of the
inner/outer rotation torque due to ad-/abduction angle is analyzed
in experiments with fixed ad-/abduction. From the experiments,
we clarify the ad-/abduction motion suppressing the inner/outer
rotation torque. To realize the clarified ad-/abduction motion, we
developed the CPM device that has two d.o.f with the inner/outer
rotation and the ad-/abduction. Finally, the experiment with the
CPM device is performed in order to confirm that this motion is
effective to suppress the excessive inner/outer rotation torque of
the shoulder joint.
Index Terms—Continuous passive motion, rehabilitation, in-
ner/outer rotation, ad-/abduction, shoulder joint, CPM device
I. I NTRODUCTION
As human utilizes many degrees of the freedom of joints
for daily living and working, reduction or loss of degree of
the freedom will deteriorate the quality of life(QOL). The
number of people who have arthritic disorders increases as
the population ages. So, it will be important to recover joint
functions immediately, and many studies have been reported
on the development and application of orthopedic treatment or
rehabilitation training devices[1][2].
Among this tendency, continuous passive motion (CPM)
was proposed as an orthopedic treatment or physiotherapy
method that promotes the recovery of the impaired joint.
This treatment method is effective to promote blood current,
regenerate periarticular tissues and increase joint ROM (Range
of motion)[3]. There are many researches about the CPM
devices for the lower limbs such as the knee joint and
femoral joint[6][7]. CPM devices for the lower limbs have
been widely used, and it was reported that these devices
induce quick recovery and are effective to expand joint Range
of motion[6][8][9]. However, there have been few clinical
cases of CPM devices for the shoulder joint because of the
musculoskeletal complex even though there are a number of
patients who have disorders in the shoulder joint. A symptom
of frozen shoulder, a major disorders in shoulder, is a decrease
of joint ROM. In order to improve the decreased ROM of
the shoulder, it is well known that the CPM performing
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inner/outer rotation is indispensable[10]. The shoulder joint
has a anatomical complexity that the inner/outer rotation torque
varies due to ad-/abduction angle. It is generally important to
reduce load to joint tissue at the ROM limitation, and it is
expected that inner/outer rotation torque is reduced by adequate
ad-/abduction motion.
Some CPM devices produced on the market can perform
inner/outer rotation and ad-/abduction[19][20]. But, these de-
vices are used in seated position or standing position, and
involve a serious problem that the device allows compensatory
movement of scapula. It causes that the devices do not ac-
complish high benefit for treatment. Also, these devices have
another problem that inadequate ad-/abduction motion increase
inner/outer rotation torque excessively since the ad-/abduction
motion is set by co-medical intuitively. For the former problem,
the authors have developed the CPM device used at dorsal
position that can suppress the compensatory motion of scapula,
and the device is highly evaluated in fields[10][11]. However,
the latter problem is unsolved because the develped device
performs only inner/outer rotation with fixed ad-/abduction. To
solve both problems, it is necessary to clarify the ad-/abduction
motion suppressing inner/outer rotation torque and to develop
the CPM device used in dorsal position that performs both
inner/outer rotation and ad-/abduction.
In this paper, through measurement experiments conducted
on CPM for shoulder joint that performs inner/outer rotation,
we first clarify the ad-/abduction motion that suppresses the
torque at ROM limitation of both inner and outer rotation.
Secondly, for suppressing the torque at both ROM limitation,
we develop the CPM device that has two d.o.f and performs the
inner/outer rotation and the ad-/abduction. Finally, the exper-
iment with the CPM device is conducted in order to confirm
that the clarified motion of the ad-/abduction is effective to
suppress the excessive inner/outer rotation torque.
II. I SSUES ON CPM DEVICE
The joint called shoulder is a compound joint that consists
of the scapulohumeral joint, the humerus and the scapula as
shown in Fig.1[12]. We call the scapulohumeral joint as shoul-
der joint. It is well known that the scapula moves excessively
in the case that the ROM of shoulder joint is decreased due to
the joint disorders such as the frozen shoulder[13]. The frozen
shoulder is a typical disorders in the shoulder joint which a
number of middle aged and older people suffer from[18].
 Figure 1. The skeletal structure of the shoulder joint[14]
Figure 2. CPM device for upper limbs (AH706)

In sound shoulder, outer rotation occur as upper arm ele-

vates in order to avoid impingement of articular tissues. This installation angle as shown in Fig.3, and the installation angle
outer rotation allow rangy elevation of upper arm. In frozen is set by co-medical such as physical therapists or doctors
shoulder, the ROM of inner/outer rotation is decreased, and the intuitively. The inner/outer rotation torque becomes large ex-
reachable range of the hand is seriously reduced according to cessively in the case that the ad-/abduction angle is inadequate.
the decreased ROM of outer rotation and of elevating direction The excessive torque deteriorates the arthritic disorder. Thus,
in addition to ROM reduction of inner rotation. Thus, the CPM the latter problem is unsolved. To solve both problems, it
performing inner/outer rotation is indispensable in order to is necessary to clarify the ad-/abduction motion suppressing
increase the ROM of the frozen shoulder[10]. inner/outer rotation torque and to develop the CPM device used
From anatomical articular structure of the shoulder, the in dorsal position which performs both inner/outer rotation and
inner/outer rotation torque varies due to ad-/abduction angle. ad-/abduction.
It is generally important to reduce load to joint tissue at the
ROM limitation, and it is expected that inner/outer rotation
torque is reduced by adequate ad-/abduction motion.
The CPM devices for shoulder joint produced on the market
perform inner/outer rotation and ad-/abduction[19][20]. These
devices involve the problem that the device cannot suppress
compensatory movement of the scapula because the devices
are used in seated position or standing position. It causes that
the devices can not accomplish high benefit for treatment.
In addition, the ad-/abduction motion of the device is set
by co-medical intuitively because the adequate ad-/abduction (a) Adduction position

suppressing the inner/outer rotation torque is not clarified.

So, these devices have another problem that inadequate ad-
/abduction motion increases inner/outer rotation torque exces-
sively. For the former problem, the authors have developed
the CPM device used at dorsal position in bedside(AH706,
Advanced Health Co., Ltd.). The developed device is shown
in Fig.2. This device suppresses the compensatory motion of
scapula due to the reaction force from the supporting plate,
and the device is highly evaluated in clinical fields[10][11]. (b) Abduction position
This device performs only inner/outer rotation with fixed
ad-/abduction. The fixed ad-/abduction angle is tuned with Figure 3. The shoulder CPM with AH706

2008 IEEE International Conference on Systems, Man and Cybernetics (SMC 2008) 531
 III. M EASUREMENT EXPERIMENTS
A. Experimental measurement system
In order to clarify the ad-/abduction that is effective to sup-
press the inner/outer rotation torque, we examine the variation
of the inner/outer rotation torque due to the ad-/abduction
angle. Measurement experiments are conducted using the
CPM device that performs inner/outer rotation with fixed ad-
/abduction which is altered using the device in Fig.3. The
CPM device for measurement is shown in Fig.4. A DC motor
Figure 4. Experimental system
with encoder is attached at the rotation shaft of the inner/outer
rotation, which measures and controls the inner/outer rotation
angle. A force sensor is attached at the end of the arm and
can measure the force of hand of the subject. The wrist is
secured by the belt at the end of the arm so as not to generate
measurement error due to the palmar flexion and the dorsal
extension of the wrist.
For safeness, the range of the inner/outer rotation angle
θin in measurements is determined so as not to generate pain.
The range of the inner/outer rotation without pain is measured
conservatively before the measurement experiments. In these
experiments, the range is set as -110[deg]≤ θin ≤90[deg].
The inner/outer rotation torque is measured with several
fixed ad-/abduction angles θa . The range of the ad-/abduction
angle is determined as -50[deg]≤ θa ≤20[deg] not to occur
the interference between the arm and body of the subject. The
adduction angle is set at every 10[deg] in the range.
B. Calculation of the inner/outer rotation torque
The inner rotation torque can be calculated using the
force measured by the force sensor. In order to calculate the
inner/outer rotation torque, we use the link model as shown in
Fig.5. In the figure, Fe , τin are the hand force in the direction
of the motion of the arm end, and the torque of inner rotation,
respectively. le , Mg and lg are the length from rotation center
to hand, the mass of the human arm and the center of mass,
532 2008 IEEE International Conference on Systems, Man and Cybernetics (SMC 2008)
Figure 5. Model of upper limbs
respectively. From the relationship between Fe and τin , τin
can be derived as
Mg glg sinθe − Fe
τin = (1)
le
whrere, le and gravity term are le = 0.4[m] and Mg glg /le =
25.8[N], respectively.
C. Measurement results
In the experiments, initial angle of upper limb was set as
follows; the angle of forearm was perpendicular to the ground,
the angle between the forearm and upper arm was 90[deg].
The measurement value of the force sensor was set as 0[N]
at the initial position. The subject in experiments received the
instruction not to generate force consciously as possible. The
arm of the CPM device was velocity controlled by PD control,
and the velocity was 0.75[rpm]. The PD gain was determined
by trial and error.
The measurement results of inner/outer rotation torque are
shown in Fig.6. From the figure, the inner rotation torque
increases as the scapulohumeral joint joint is outer rotated
and decreases as the joint is internally rotated. At the inner
rotation : θin = 90[deg], the amplitude of τin decreases from
89.8 to 37.5 as the scapulohumeral joint is adducted from
θa = -50[deg] to θa = 0[deg], and increases from 37.5[Nm]
to 44.4[Nm] from θa = 0[deg] to θa = 20[deg]. Thus, θa
minimizing the amplitude of τin at inner rotation is 0[deg]. At
outer rotation : θin =-110[deg], τin decreases from 40.1[Nm]
to 28.8[Nm] as the joint is adducted from θa = -50[deg] to
θa = -30[deg], and increases from θa = -30[deg] to θa =
20[deg]. Thereby, θa minimizing τin at outer rotation is around
-30[deg]. From above, θa minimizing the amplitude of τin at
inner rotation and outer rotation is different.
 Figure 6. ROM in CPM with inner/outer rotation
IV. CPM WITH AD -/ ABDUCTION AND INNER / OUTER
ROTATION
In general, CPM accomplishes the effectiveness by pumping
effect generated by variation of intra-articular pressure due
to reciprocal joint motion[4][5]. To accomplish high effec-
tiveness, it is preferable to increase the number of reciprocal
motion. CPM also need to be performed with slow velocity.
Hence, following conditions should be considered.
I) The number of the reciprocation of the arm is large in a
certain time period.
II) The arm motion is as slow as possible.
The ad-/abduction angle suppressing the torque at inner
rotation position is different from that at outer rotation position.
Conservatively, it is suppressible to separately perform CPM
for inner rotation and outer rotation, which is set ad-/abduction
angle suppressing the torque at inner and outer rotation,
respectively. From condition (I), however, it is preferable to
suppress the torque at ROM limitation of both inner and
outer rotation in a same CPM treatment simultaneously. Hence,
CPM performing both inner/outer rotation and ad-/abduction
is necessary.
For control of the ad-/abduction while inner/outer rotation,
we have developed the experimental CPM device that has two
d.o.f with inner/outer rotation and the ad-/abduction, which is
shown in Fig.7. A force sensor (IFS-50M31A25-I25, made by
NITTA corporation) is attached at the end of the arm, which
can measure the force of hand. The DC motors (15[W], Gear
ratio : 500) and encoders (500[ppr]) are attached in the rotation
shafts of the inner/outer rotation and ad-/abduction, and control
and measure the angle of the both motions. The specification
of actuator is shown in Table.I. The arm length of the CPM
device can be tuned for individual differences.
2008 IEEE International Conference on Systems, Man and Cybernetics (SMC 2008)
Figure 7. CPM device with the inner/outer rotation and the ad-/abduction
Table I
S PECIFICATION OF THE CPM DEVICE
Ad-/abduction and inner/outer rotation torque 64.5 [Nm]
Range of inner/outer rotation ± 115 [deg]
Range of ad-/abduction ± 80 [deg]
Forearm length 160 to 400 [mm]
Upper arm length 230 to 290 [mm]
The trajectory of the CPM should be via the quickest route.
An adequate trajectory of θa w.r.t θin is the straight line that
connects (θin , θa )=(-110, -30) and (θin , θa )=(90, 0). Hence,
the line can be regarded as the reference trajectory of the ad-
/abduction, which is represented as θa = 0.15θin − 13.5. The
experimental CPM is conducted in order to validate that the
CPM that performs the both motion is effective to suppress
the inner/outer rotation torque.
In the experiment, the ad-/abduction angle is controlled by
the PD control in order to follow the reference trajectory. The
inner/outer rotation is velocity controlled, and the reference
velocity is 0.75[rpm] according to the specification of the
device shown in Fig.2 which is highly evaluated in fields.
The experimental result is shown as the red line in Fig.8.
From the figure, the amplitude of τin is reduced at both inner
and outer rotation. The amplitude of τin at the inner rotation
is reduced from 50.5[Nm] to 27.7[Nm] by comparison with
the CPM at θa = 0 represented as the blue line, and from
49.6[Nm] to 36.3[Nm] by comparison with the CPM at θa =
533

Figure 8. The inner rotation torque in CPM with inner/outer rotation and
ad-/abduction
-30 represented as the black line. Therefore, it is confirmed
that the CPM that performs the inner/outer rotation and the
ad-/abduction is effective to suppress the inner/outer rotation
torque.
V. C ONCLUSION
In this paper, measurement experiments were conducted on
CPM device that performs inner/outer rotation with fixed ad-
/abduction, and it was clarified that the ad-/abduction angle
that minimizes the inner/outer rotation torque at inner rotation
and outer rotation is different. For suppressing the torque at
both inner and outer rotation, we have developed the CPM
device that has two d.o.f and performs the inner/outer rotation
and the ad-/abduction. The experiment with the developed
CPM device was performed in order to validate the CPM
that performs the inner/outer rotation and ad-/abduction is
effective to suppress the excessive inner/outer rotation torque.
From the experimental result, it was confirmed that the CPM
that perform the inner/outer rotation and the ad-/abduction is
effective to suppress the inner/outer rotation torque.
Our future works is to develop the control low to realize the
therapeutically effective motion of the CPM device based on
the musculoskeletal model of the shoulder joint. Additionally,
the individual difference and the evaluation from the viewpoint
of medical sense are the future work.
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