Development and application of a multi-axis dynamometer for measuring grip force.

OBJECTIVE: This paper describes the development and application of a novel multi-axis hand dynamometer for quantifying 2D grip force magnitude and direction in the flexion-extension plane of the fingers. METHODS: A three-beam reconfigurable form dynamometer, containing two active beams for measuring orthogonal forces and moments regardless of point of force application, was designed, fabricated and tested. Maximum grip exertions were evaluated for 16 subjects gripping cylindrical handles varying in diameter. RESULTS: Mean grip force magnitudes were 231 N (SD = 67.7 N), 236 N (72.9 N), 208 N (72.5 N) and 158 N (45.7 N) for 3.81 cm, 5.08 cm, 6.35 cm and 7.62 cm diameter handles, respectively. Grip force direction rotated clockwise and the centre of pressure moved upward along the handle as handle diameter increased. CONCLUSIONS: Given that the multi-axis dynamometer simultaneously measures planar grip force magnitude and direction, and centre of pressure along the handle, this novel sensor design provides more grip force characteristics than current sensor designs that would improve evaluation of grip characteristics and model-driven calculations of musculoskeletal forces from dynamometer data.

Evaluation of a modified Fitts law brain-computer interface target acquisition task in able and motor disabled individuals.

A brain-computer interface (BCI) is a communication system that takes recorded brain signals and translates them into real-time actions, in this case movement of a cursor on a computer screen. This work applied Fitts' law to the evaluation of performance on a target acquisition task during sensorimotor rhythm-based BCI training. Fitts' law, which has been used as a predictor of movement time in studies of human movement, was used here to determine the information transfer rate, which was based on target acquisition time and target difficulty. The information transfer rate was used to make comparisons between control modalities and subject groups on the same task. Data were analyzed from eight able-bodied and five motor disabled participants who wore an electrode cap that recorded and translated their electroencephalogram (EEG) signals into computer cursor movements. Direct comparisons were made between able-bodied and disabled subjects, and between EEG and joystick cursor control in able-bodied subjects. Fitts' law aptly described the relationship between movement time and index of difficulty for each task movement direction when evaluated separately and averaged together. This study showed that Fitts' law can be successfully applied to computer cursor movement controlled by neural signals.

A new method for estimating hand internal loads from external force measurements.

This study examines using force vectors measured using a directional strain gauge grip dynamometer for estimating finger flexor tendon tension. Fifty-three right-handed participants (25 males and 28 females) grasped varying-sized instrumented cylinders (2.54, 3.81, 5.08, 6.35 and 7.62 cm diameter) using a maximal voluntary power grip. The grip force vector magnitude and direction, referenced to the third metacarpal, was resolved by taking two orthogonal grip force measurements. A simple biomechanical model incorporating the flexor tendons was used to estimate long finger tendon tension during power grip. The flexor digitorum superficialis and the flexor digitorum profundus were assumed to create a moment about the metacarpal phalange (MCP) joint that equals and counteracts a moment around the MCP joint measured externally by the dynamometer. The model revealed that tendon tension increased by 130% from the smallest size handle to the largest, even though grip force magnitude decreased 36% for the same handles. The study demonstrates that grip force vectors may be useful for estimating internal hand forces.

Short-term changes in upper extremity dynamic mechanical response parameters following power hand tool use.

Dynamic mechanical response parameters (stiffness, damping and effective mass), physiological properties (strength and swelling) and symptoms of the upper limb were measured before power tool operation, immediately following and 24 h after power tool operation. Tool factors, including peak torque (3 Nm and 9 Nm) and torque build-up time (50 ms and 250 ms), were controlled in a full factorial design. Twenty-nine inexperienced power hand tool users were randomly assigned to one of four conditions and operated a pistol grip nutrunner four times per min for 1 h in the laboratory. Isometric strength decreased immediately following tool use (15%) (p < 0.01) and 24 h later (9%) (p < 0.05). Mechanical parameters of stiffness (p < 0.05) and effective mass (p < 0.05) were affected by build-up time. An average decrease in stiffness (43%) and effective mass (57%) of the upper limb was observed immediately following pistol grip nutrunner operation for the long (250 ms) build-up time. A previously developed biomechanical model was used to estimate handle force and displacement associated with the tool factors in the experiment. The conditions associated with the greatest predicted handle force and displacement had the greatest decrease in mechanical stiffness and effective mass, and the greatest increase in localized discomfort.

The influence of knife dullness on poultry processing operator exertions and the effectiveness of periodic knife steeling.

A novel procedure is described to establish knife steeling schedules for poultry and meat- processing operations based on increased force due to knife dullness from repetitive use to minimize operator exertions and physical stress associated with work-related musculoskeletal disorders. Knife dullness was quantified using a novel apparatus described in this article that measures the area cut by a knife into a carrageenan gel target for a controlled dynamic load at the knife handle. Two meat-cleaning jobs in a poultry-processing plant were studied. One job required significantly more force and a greater number of cuts than the other. Eight experienced operators participated in the study. Four freshly ground and honed knives were randomly used by each operator for 4, 45, 75, or 125 cutting cycles, measured for dullness and reconditioned by the operator using a steel sharpening rod. An empirical model for knife dulling and reconditioning was developed, and the corresponding increase in force was predicted for various cutting and reconditioning frequencies. The model showed that it took 57 and 125 cutting cycles for the high- and low-force jobs, respectively, to achieve a similar reduction in target surface area of 30%. This reduction in target surface area corresponded to a similar percentage increase in force needed for the same cut in carrageenan gel as compared to a freshly honed knife as measured using strain gages. This method may be used in meat processing plants for determining effective reconditioning schedules that reduce operator exertions with minimum effect on quality and productivity.

Dynamic biomechanical model of the hand and arm in pistol grip power handtool usage.

The study considers the dynamic nature of the human power handtool operator as a single degree-of-freedom mechanical torsional system. The hand and arm are, therefore, represented as a single mass, spring and damper. The values of these mechanical elements are dependent on the posture used and operator. The apparatus used to quantify these elements measured the free vibration frequency and amplitude decay of a known system due to the external loading of the hand and arm. Twenty-five subjects participated in the investigation. A full factorial experiment tested the effects on the three passive elements in the model when operators exerted maximum effort for gender, horizontal distance (30, 60, 90 cm), and vertical distance (55, 93, 142 190 cm) from the ankles to the handle. The results show that the spring element stiffness and mass moment of inertia changed by 20.6 and 44.5% respectively with vertical location (p<0.01), and 23.6 and 41.2% respectively with horizontal location (p<0.01). Mass moment of inertia and viscous damping for males were 31.1 and 38.5% respectively greater than for females (p<0.01). Tool handle displacement and hand force during torque build-up can, therefore, be predicted based on this model for different tool and workplace parameters. The biomechanical model was validated by recalling five subjects and having them operate a power handtool for varying horizontal distances (30, 60, 90 cm), vertical distances (55, 93, 142 cm), and two torque build-up times (70, 200 ms). Tool reaction displacement was measured using a 3D-motion analysis system. The predictions were closely correlated with these measurements (R = 0.88), although the model underpredicted the response by 27%. This was anticipated since it was unlikely that operators used maximal exertions for operating the tools.

Comparison between using spectral analysis of electrogoniometer data and observational analysis to quantify repetitive motion and ergonomic changes in cyclical industrial work.

Spectral analysis of continuously measured joint angles using an electrogoniometer was considered as a potentially efficient method for quantifying exposure to physical stress in repetitive manual work. The method was previously demonstrated in the laboratory but has not yet been tested extensively in the field. Spectral analysis was compared against observational analysis, consisting of time-and-motion study and posture classification. Six industrial jobs were selected: (1) press operation, (2) large parts hanging, (3) product packaging, (4) small parts hanging, (5) parts counting and sorting and (6) construction vehicle operation. The posture angle data were synchronized with activities on the video using an interactive multimedia video data acquisition system. Motion for every joint was analyzed using both spectral analysis and observational analysis. Joint angles for the wrist, elbow and shoulder were directly measured using electrogoniometers. Visual posture classification involved determining joint angles from a frozen videotape image sampled three times per s. Repetitiveness was quantified for observational analysis using time study to measure the frequency that specific motions repeat, while spectral analysis measured repetitiveness as the frequency where spectral peaks occurred. Spectral analysis agreed closely with observational analysis. Correlation between the repetition frequencies obtained using time study and spectral analysis was 0.97, with no statistically significant difference observed. Average sustained posture was quantified as the mean, and posture deviation as the RMS angle of joint motion. No statistically significant differences between data obtained using posture classification or spectral analysis were observed for either posture deviation or sustained posture. Since posture classification was very limited in resolution and often contained measurement errors caused by poor joint visibility, the correlation between the postural classification and spectral analysis was 0.77 for sustained posture and 0.53 for posture deviation. When considering only large motions that exceeded the posture classification angle precision, the correlation between postural classification and spectral analysis was 0.81 for sustained posture and 0.81 for posture deviation. Spectral analysis of electrogoniometer data were, therefore, an efficient method for analyzing repetitive manual work that obtained equivalent results, and was more precise than observational analysis.

Neuromuscular and psychological characteristics in subjects with work-related forearm pain.

There are scant data available on the neuromuscular and psychological characteristics of patients with cumulative trauma disorders. We compared 16 subjects with work-related forearm and hand pain in the dominant upper limb with 9 age-matched control subjects. Pain subjects were divided into two groups based on nerve conduction studies: eight subjects were in the study group for median neuropathy at the wrist (MN, median transcarpal latency >2.3 ms), and eight were in the study group for electrodiagnostically negative pain (EN). Average pain, forearm muscle tenderness, grip strength, pinch strength, and wrist flexor and extensor strength were measured. The Health Status Questionnaire and the Beck Depression Inventory were used to measure health perception and depressive symptoms, respectively. Work satisfaction was determined by a newly devised scale. Statistical analysis was by analysis of variance and planned comparison analysis. The MN and EN groups did not significantly differ on any of the measures except median transcarpal latency. Both pain groups had significantly (P < 0.05) greater average pain, greater extensor muscle tenderness, higher Beck Depression Inventory scores, higher pain rating, and poorer physical functioning on the Health Status Questionnaire than did the normal control group. Grip strength and wrist extension force were diminished in both cumulative trauma groups compared with control subjects; however, only grip strength in the MN group and wrist extension force in the EN group differed significantly (P < 0.05) from control subjects. Only the EN group had significantly less work satisfaction than did the control group. Overall, both pain groups differed from control subjects and shared similar characteristics, with the exception of median neuropathy.

Computer key switch force-displacement characteristics and short-term effects on localized fatigue.

This study investigates the effects of key switch design parameters on short-term localized muscle fatigue in the forearm and hand. An experimental apparatus was utilized for simulating and controlling key switch make force and travel using leaf spring mechanisms, and provided direct measurement of applied key strike force using strain gauge load cells. Repetitive key tapping was performed as fast as possible using the dominant index finger for 500 s per condition (8.3 min) and a work-rest schedule consisting of 15 s of key tapping alternating with 10 s of rest. One combination of two make force levels (0.31 and 0.71 N) and two over travel distances (0.5 and 4.5 mm) was presented randomly on four different days. Nine subjects participated. Localized muscle fatigue in the hand and forearm was assessed subjectively using a 10 cm visual analogue scale, and objectively using surface electromyography (EMG). Average peak key strike force exerted was 0.35 N less for the smaller make force and 0.59 N less for the longer over travel distance. Fatigue occurred in all cases but no significant differences were observed between key switch parameters based on RMS EMG. Subjective reports of localized fatigue after 500 s were less when the key switch make force was less; however, a corresponding over travel effect was not observed despite the greatly reduced key strike force for the longer over travel distance. This discrepancy may be explained by the greater finger movement that was observed with increased over travel. Although there was no apparent improvement in short-term discomfort from fatigue when over travel was increased, this study did not consider the potential long-term health benefits from reduced key strike force.

Model for the administration of low-flow anaesthesia.

A general (multiple-gas) three-compartment mass-balance model of the circle-absorber breathing circuit with intermittent positive-pressure ventilation has been developed. We propose it as a tool to determine flowmeter and vapourizer settings for inhalation anaesthesia by low-flow methods (less than 1 litre min-1 total fresh gas flow). This model reproduces the results of various previously-published mass-balance models, but it appears to underestimate slightly the delivery of fresh gases to the inspired limb of the breathing circuit when tested with clinical data from surgical cases. Low-flow dosing schedules for 35% inspired oxygen and 1% inspired halothane were computed with the model and tested in vitro with a circle-absorber breathing circuit and an active gas-exchange lung at nine values of simulated patient gas exchanges. The mean inspired oxygen concentration over all trials was 32.8% (SD = 1.9%), while the mean inspired halothane concentration was 1.2% (SD = 0.3%). The flow meter and vapourizer settings calculated from the model appear to have sufficient accuracy to be useful in the clinical setting in conjunction with active oxygen and anaesthetic agent monitoring.

Agreement between a frequency-weighted filter for continuous biomechanical measurements of repetitive wrist flexion against a load and published psychophysical data.

A previous pilot study demonstrated that a force and frequency-weighted filter network could be developed for processing continuous biomechanical measures of repetitive wrist motions and exertions. The current study achieves the objective by modelling subjective discomfort for repetitive wrist flexion using controlled posture, pace and force. A three-level fractional factorial experiment was conducted involving repetitive wrist flexion (2 s/motion, 6 s/motion, 10 s/motion) from a neutral posture to a given angle (10 degrees, 28 degrees, 45 degrees) against a controlled resistance (5 N, 25 N, 50 N) using a Box Behnken design. Ten subjects participated. Discomfort was reported on a 10 cm visual analogue scale. Results of response surface regression analysis revealed that main effects of force, wrist flexion angle, and repetition were all significant (p < 0.05) and that no second-order effects were observed. Linear regression analysis on these factors established a discomfort model on which the filter characteristics were based. The pure error test model revealed no significant lack of fit (p > 0.05). The continuous model was compared and agreed with discrete psychophysical data from other published studies. The model was used for generating parameters for a force and frequency-weighted digital filter that weighs continuous wrist postural signals with corresponding force in proportion to the equal discomfort function as a function of frequency of repetition. These filters will enable integration of large quantities of biomechanical data in field studies.

Validation of a frequency-weighted filter for continuous biomechanical stress in repetitive wrist flexion tasks against a load.

This experiment validates a frequency-weighted filter for continuous measurements of force, posture and repetition using a stimulated industrial task. A peg transfer task was used requiring subjects to repetitively insert pegs into holes with controlled resistance. Ten subjects performed the task for six conditions. All wrist flexion angular data were recorded continually using an electrogoniometer and processed through the filter. Subjective discomfort was reported after performing the task for 1 h using a 10 cm visual analogue scale. Results from linear regression analysis showed that the instrument reliably estimated subjective discomfort (r2 = 0.873). Applications and limitations of this instrument are explored.

The influence of target torque and torque build-up time on physical stress in right angle nutrunner operation.

This study used a computer-controlled electric right angle nutrunner to investigate the relative effects of different power hand tool and process parameters on operator muscular exertions, handle stability and subjective ratings of perceived exertion. Target torque (25, 40 and 55 Nm), torque build-up time (35, 150, 300, 500 and 900 ms), and workstation orientation (horizontal and vertical) were studied. Dependent variables included EMG activity of the finger flexors, biceps, and triceps, handle velocity and displacement, work done on the tool-hand system and power involved in doing work, subjective ratings of perceived exertion, and task acceptance. Six inexperienced subjects (three females and three males) participated. Ten replications were performed for each combination of experimental conditions. The consequences of increasing the torque reaction force were greater handle instability and perceived exertion. The effect of torque build-up time on handle kinematics, muscular activity and perceived exertion was not monotonic. Among five build-up times tested, the hand was most unstable (greater peak handle velocity and power against the operator) for a 150 ms build-up time. Greater peak handle displacement, total work against the operator and average EMG were observed for 150 and 300 ms build-up times than for other build-up time conditions. Integrated EMG and EMG latency significantly increased as build-up time increased. Average EMG latency between the onset of EMG burst and the onset of torque build-up was 40 ms for a 35 ms build-up time and 330 ms for a 900 ms build-up time. Subjective ratings of perceived exertion were the least when torque build-up time was 35 ms, however greater peak torque variance was associated with this condition.

A silicon-based tactile sensor for finger-mounted applications.

This paper presents a silicon-based force sensor packaged in a flexible package and describes the sensors performance on human subjects. The sensing element consists of a circular silicon diaphragm (200-micron thick with a 2-mm radius) over a 10-micron sealed cavity with a solid Torlon dome providing force-to-pressure transduction to the diaphragm. Two dome heights (0.5 and 1.5 mm) were compared. The sensor with the taller dome showed improved sensitivity. Dynamic calibration and tracking experiments are performed with the sensor mounted on the dominant thumb of five human subjects. Both force and loading direction are statistically significant (P < 0.05). Subject variability accounted for 8.7% of the variance, while loading direction accounted for 1.9% of the variance. Average errors for the tracking experiment range from-2.8 to 1.0 N and are subject dependent. Three out of four subjects showed increasing negative error with increasing load.

A dynamic mechanical model for hand force in right angle nutrunner operation.

A deterministic mechanical model based on physical tool parameters was used for estimating static and dynamic hand forces from kinematic measurements. We investigated the effects of target torque (25, 40, and 55 Nm) and threaded fastener joint hardness (35-, 150-, 300-, 500-, and 900-ms torque buildup time) on hand force. Estimated hand force was affected by target torque and joint hardness. Peak and average dynamic hand force was least for the hard joint (35-ms buildup) and greatest for the medium hardness joint (150-ms buildup). Tool inertia played the major role in reducing hand reaction force. Estimated hand force decreased when the inertial force component increased. Inertial force decreased by 366% when buildup time increased from 35 to 300 ms. Static modeling overestimated hand force; the error ranged from 10% for a soft joint to 40% for a hard joint. Results from direct hand force measurements using a strain gauge dynamometer showed that the dynamic model overestimated peak hand force by 9%. However, average hand force and force impulse were not significantly overestimated.

Comparison of impedance and inductance ventilation sensors on adults during breathing, motion, and simulated airway obstruction.

The goal of this study was to compare the relative performance of two noninvasive ventilation sensing technologies on adults during artifacts. We recorded changes in transthoracic impedance and cross-sectional area of the abdomen (abd) and rib cage (rc) using impedance pneumography (IP) and respiratory inductance plethysmography (RIP) on ten adult subjects during natural breathing, motion artifact, simulated airway obstruction, yawning, snoring, apnea, and coughing. We used a pneumotachometer to measure air flow and tidal volume as the standard. We calibrated all sensors during natural breathing, and performed measurements during all maneuvers without changing the calibration parameters. No sensor provided the most-accurate measure of tidal volume for all maneuvers. Overall, the combination of inductance sensors [RIP(sum)] calibrated during an isovolume maneuver had a bias (weighted mean difference) as low or lower than all individual sensors and all combinations of sensors. The IP(rc) sensor had a bias as low or lower than any individual sensor. The cross-correlation coefficient between sensors was high during natural breathing, but decreased during artifacts. The cross correlation between sensor pairs was lower during artifacts without breathing than it was during maneuvers with breathing for four different sensor combinations. We tested a simple breath-detection algorithm on all sensors and found that RIP(sum) resulted in the fewest number of false breath detections, with sensitivity of 90.8% and positive predictivity of 93.6%.

A single metric for quantifying biomechanical stress in repetitive motions and exertions.

The relative effects of repetition, force and posture were studied in order to investigate how continuous biomechanical measurements can be combined into a single metric corresponding to subjective discomfort. A full factorial experiment was conducted involving repetitive wrist flexion from a neutral posture to a given angle against a controlled force. Seven subjects performed the task using two paces (20 and 4 motions/min), two force levels (15 and 45 N) and two angles (15 and 45 degrees) for 1 h each. Discomfort was reported on a 10 cm visual analogue scale anchored between 'no discomfort' and 'very high discomfort'. Repeated measures analysis of variance showed that all main effects were statistically significant (p < 0.05) and no significant interactions were observed. A linear regression model was fitted to the data and used for generating frequency weighted digital filters that shape continuous recordings of repetitive motions and exertions into an output proportional to relative discomfort. The resulting high-pass digital filter had a 22 dB/decade attenuation slope. A simulated industrial task used for validating the model involved repetitively transferring pegs across a horizontal bar and inserting them into holes against a controlled resistance. Angular wrist data were recorded using an electrogoniometer and filtered. Six subjects performed the task of the three conditions consisting of (1) 15 wrist flexion, 15 N resistance and 6 motions min, (2) 15 wrist flexion. 45 N resistance and 12 motions/min, and (3) 45 degrees wrist flexion, 45 N resistance and 15 motions/min. Subjective discomfort was reported after performing the task for 1 h. Pearson correlations between subjective discomfort ratings and the integrated filtered biomechanical data for individual subjects ranged from 0.90 to 1.00. The pooled correlation across subjects was 0.67. This approach may be useful for physical stress exposure assessment and for design of tasks involving repetitive motions and exertions.

Activation force and travel effects on overexertion in repetitive key tapping.

Key switch design parameters, including make force, make travel, and over travel, were investigated for minimizing operator-exerted force while maximizing key-tapping speed. A mechanical apparatus was designed, constructed, and used for independently controlling key switch parameters and for directly measuring finger exertions during repetitive key tapping using strain gauge load cells. The task for the 25 participants involved using the index finger of the dominant hand to repeatedly depress a single key as rapidly as possible. Participants received visual and auditory feedback upon a successful keystroke. Peak force exerted decreased 24% and key-tapping rate increased 2% when over travel was distended from 0.0 to 3.0 mm. Although peak force exerted was not significantly affected by make point travel, key-tapping rate increased 2% when make point travel was reduced from 4.0 to 1.0 mm. These results indicate that key switch mechanisms that provide adequate over travel might enable operators to exert less force during repetitive key tapping without inhibiting performance.

Preliminary evaluation of a sensory and psychomotor functional test battery for carpal tunnel syndrome: Part 1--Confirmed cases and normal subjects.

Two new computer-controlled functional tests were developed, known as the Wisconsin test battery, for carpal tunnel syndrome (CTS). The gap detection sensory test quantifies tactile thresholds for areas of the hand innervated by the median nerve. The rapid pinch and release psychomotor test measures the initiation and control of specific muscles innervated by the median nerve motor branch. Ten confirmed CTS patients (based on electrophysiological parameters and examination; 18 CTS hands) and eight confirmed normal subjects (16 hands) with a similar average age were administered both tests. The CTS patients showed significant functional deficits for both tactility and psychomotor tests. Average CTS performance was 24 to 104% poorer than for the normal subjects, depending on the performance measure. The results indicated high correlations (r = 0.5 to 0.8) between median nerve electrophysiological parameters and tactility or psychomotor performance variables. No single functional test variable had sufficient sensitivity for detecting CTS among the subject pool. The combination of the two tests using 95% confidence level cutoff points achieved a sensitivity of 0.78 and a specificity of 0.81. Stepwise discriminant analysis resulted in two performance variables capable of a sensitivity of 0.72 and a specificity of 0.94 for differentiating well-defined CTS subjects from normal subjects. Despite these promising results, limitations of the study include small sample size and subject selection bias. Further studies are needed for verifying the utility of the functional test battery for detecting CTS in a general population.

Preliminary evaluation of a sensory and psychomotor functional test battery for carpal tunnel syndrome: Part 2--Industrial subjects.

This study evaluated the Wisconsin functional sensory and psychomotor test battery for carpal tunnel syndrome (CTS). Subjects were 27 employees recruited from a food processing plant. Both hands of all subjects were examined and categorized by presence or absence of symptoms and nerve conduction study (NCS) findings (Symptom-/NCS-, Symptom+/NCS-, Symptom-/NCS+, and Symptom+/NCS+). Symptom-/NCS- category hands had significantly better performance (15-60%) for most of the functional test battery variables than Symptom+/NCS+ category hands. A significant gap detection threshold difference (32%) was observed between NCS+ and NCS- hands regardless of symptoms, with NCS- having impaired performance. No significant effect of CTS symptoms on performance was observed. Stepwise discriminant analysis was used to select the best variables to differentiate between groups. The ratio of the change in pinch rate with respect to required pinch force differentiated NCS+ from NCS- hands, with a sensitivity of 0.71 and a specificity of 0.68. The same variable had a sensitivity of 0.74 and specificity of 0.83 for distinguishing Symptom-/NCS- hands from all other categories. Pinch rate had a sensitivity of 0.82 and a specificity of 0.81 for separating Symptom+/NCS+ hands from all other categories. Use of both gap detection threshold and the ratio of the change in pinch rate with respect to required pinch force could best differentiate Symptom+/NCS+ from Symptom-/NCS- cases for a sensitivity of 0.91 and specificity of 0.87. Outcomes could not be generalized to a specific work population but demonstrate that the non-invasive test battery may be useful for providing objective measures of deficits associated with CTS symptoms and electrophysiological parameters.