Biomechanical mechanisms underlying exosuit-induced improvements in walking economy after stroke

Stroke-induced hemiparetic gait is characteristically asymmetric and metabolically expensive. Weakness and impaired control of the paretic ankle contribute to reduced forward propulsion and ground clearance—walking subtasks critical for safe and efficient locomotion. Targeted gait interventions that improve paretic ankle function after stroke are therefore warranted. We have developed textile-based, soft wearable robots that transmit mechanical power generated by off-board or body-worn actuators to the paretic ankle using Bowden cables (soft exosuits) and have demonstrated the exosuits can overcome deficits in paretic limb forward propulsion and ground clearance, ultimately reducing the metabolic cost of hemiparetic walking. This study elucidates the biomechanical mechanisms underlying exosuit-induced reductions in metabolic power. We evaluated the relationships between exosuit-induced changes in the body center of mass (COM) power generated by each limb, individual joint powers, and metabolic power. Compared to walking with an exosuit unpowered, exosuit assistance produced more symmetrical COM power generation during the critical period of the step-to-step transition (22.4±6.4% more symmetric). Changes in individual limb COM power were related to changes in paretic (R2= 0.83, P= 0.004) and nonparetic (R2= 0.73, P= 0.014) ankle power. Interestingly, despite the exosuit providing direct assistance to only the paretic limb, changes in metabolic power were related to changes in nonparetic limb COM power (R2= 0.80, P= 0.007), not paretic limb COM power (P> 0.05). These findings provide a fundamental understanding of how individuals poststroke interact with an exosuit to reduce the metabolic cost of hemiparetic walking.Accepted manuscript2019-03-0

Best practice statement : use of ankle-foot orthoses following stroke

NHS Quality Improvement Scotland (NHSQIS) leads the use of knowledge to promote improvement in the quality of health care for the people of Scotland and performs three key functions. It provides advice and guidance on effective clinical practice, including setting standards; drives and supports implementation of improvements in quality, and assessing the performance of the NHS, reporting and publishing findings

Replacing canes with an elasticated orthotic-garment in chronic stroke patients - The influence on gait and balance. A series of N-of-1 trials

Objective:To investigate the effect of replacing canes with an elasticated orthotic-garment on balanceand gait-function in chronic stroke survivors.Design:Experimental, N-of-1 series with a replicated, ABC design with randomised phase duration in ahome setting.Participants:Four cane using chronic stroke survivors (P1-4).Interventions:Phase A (9e12 weeks) cane-walking“as usual”to establish baseline values; Phase B (9e16weeks) intervention: orthotic-garment worn throughout the day with maximal cane-use reduction;Phase C (9e10 weeks) participant-determined follow-up: either no walking-aid, orthotic-garment orcane.Outcome measures:Primary: Functional-Gait-Assessment (FGA), Secondary: Trunk-sway during walkingmeasured as Total-Angle-Area (TAA�2) in frontal and sagittal-planes, both measured weekly.Results:Visual and statistical analysis of results showed significant improvements in FGA from phase Ato B in all participants. Improvement continued in phase C in P2, stabilized in P1 and P4 and deterioratedin P3. A Minimal-Clinical-Important-Difference of 6 points-change was achieved in P2&P4. Trunk-swayreduced during walking, indicating increased stability, in two participants from phase A to B and in threeparticipants from A to C but no TAA changes were statistically significant. In phase C participant-selectedwalking-aids were: P1 cane-usage reduced by 25%, P2 independent-walking with no assistive-device, S3usual cane-usage, P4 orthotic-garment with reduced cane-usage 2-3 days-a-week, usual cane-usage 4e5days.Conclusions:Although walking ability is multifactorial these results indicate that the choice of walking-aids can have a specific and clinically relevant impact on gait following stroke.“Hands-free”assistive-devices may be more effective than canes in improving gait-function in somepatients

A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO

Orthoses for Spinal Cord Injury Patients

There are some limitations for patients with spinal cord injury (SCI) when walking with assistive devices. Heavy energy expenditure and walking high loads on the upper limb joints are two main reasons of high rejection rate of orthosis by these patients . Many devices have been designed to enable people with paraplegia to ambulate in an upright position as a solution of these limitations such as mechanical orthoses, hybrid orthoses and powered orthoses. All these devices are designed to solve the problem of standing and walking, but there are some other important notes, which should be considered. For example, the size and weight of external orthoses, donning and doffing, cumbersomeness and independency for using are very important

Orthotic management of cerebral palsy : recommendations from a consensus conference

An international multidisciplinary group of healthcare professionals and researchers participated in a consensus conference on the management of cerebral palsy, convened by the International Society for Prosthetics and Orthotics. Participants reviewed the evidence and considered contemporary thinking on a range of treatment options including physical and occupational therapy, and medical, surgical and orthotic interventions. The quality of many of the reviewed papers was compromised by inadequate reporting and lack of transparency, in particular regarding the types of patients and the design of the interventions being evaluated. Substantial evidence suggests that ankle-foot orthoses (AFOs) that control the foot and ankle in stance and swing phases can improve gait efficiency in ambulant children (GMFCS levels I-III). By contrast, little high quality evidence exists to support the use of orthoses for the hip, spine or upper limb. Where the evidence for orthosis use was not compelling consensus was reached on recommendations for orthotic intervention. Subsequent group discussions identified recommendations for future research. The evidence to support using orthoses is generally limited by the brevity of follow-up periods in research studies; hence the extent to which orthoses may prevent deformities developing over time remains unclear. The full report of the conference can be accessed free of charge at www.ispoint.org

Lower-limb amputees can reduce the energy cost of walking when assisted by an Active Pelvis Orthosis

Exoskeletons could compete with active prostheses as effective aids to reduce the increased metabolic demands faced by lower-limb amputees during locomotion. However, little evidence of their efficacy with amputees has been provided so far. In this paper, a portable hip exoskeleton has been tested with seven healthy subjects and two transfemoral amputees, with the final goal to verify whether a hip flexion-extension assistance could be effective in reducing the metabolic cost of walking. The metabolic power of the participants was estimated through indirect calorimetry during alternated repetitions of three treadmill-based walking conditions: without the exoskeleton (NoExo), with the exoskeleton in zero-torque mode (ExoTM) and with the exoskeleton providing hip flexion-extension assistance (ExoAM). The results showed that the exoskeleton reduced the net metabolic power of the two amputees in ExoAM with respect to NoExo, by 5.0% and 3.4%. With healthy subjects, a 5.5±3.1% average reduction in the metabolic power was observed during ExoAM compared to ExoTM (differences were not statistically significant), whereas ExoAM required 3.9±3.0% higher metabolic power than NoExo (differences were not statistically significant). These results provide initial evidence of the potential of exoskeletal technologies for assisting lower-limb amputees, thereby paving the way for further experimentations

Role of Gait Training in Recovery of Standing and Walking in Subjects with Spinal Cord Injury

Gait training has an important role in rehabilitation of standing and walking in spinal cord injury (SCI) patients. There were different types of gait training in these subjects. Both the body weight support treadmill training and robotic-assisted and robotic exoskeleton are effective and secure methods for gait training and improving the energy demand and metabolic cost in SCI patients in different level of injury. The powered exoskeletons can provide patients with SCI the ability to walk with the lowest energy consumption. The powered exoskeleton’s energy consumption and speed of walking depend on the training duration. Based on different types of gait training methods, training time, and other affected parameters, the aim of this chapter was to evaluate the role of gait training in recovery of standing and walking in SCI patients

Design And Development of A Powered Pediatric Lower-limb Orthosis

Gait impairments from disorders such as cerebral palsy are important to address early in life. A powered lower-limb orthosis can offer therapists a rehabilitation option using robot-assisted gait training. Although there are many devices already available for the adult population, there are few powered orthoses for the pediatric population. The aim of this dissertation is to embark on the first stages of development of a powered lower-limb orthosis for gait rehabilitation and assistance of children ages 6 to 11 years with walking impairments from cerebral palsy. This dissertation presents the design requirements of the orthosis, the design and fabrication of the joint actuators, and the design and manufacturing of a provisional version of the pediatric orthosis. Preliminary results demonstrate the capabilities of the joint actuators, confirm gait tracking capabilities of the actuators in the provisional orthosis, and evaluate a standing balance control strategy on the under-actuated provisional orthosis in simulation and experiment. In addition, this dissertation presents the design methodology for an anthropometrically parametrized orthosis, the fabrication of the prototype powered orthosis using this design methodology, and experimental application of orthosis hardware in providing walking assistance with a healthy adult. The presented results suggest the developed orthosis hardware is satisfactorily capable of operation and functional with a human subject. The first stages of development in this dissertation show encouraging results and will act as a foundation for further iv development of the device for rehabilitation and assistance of children with walking impairments