The Determination of Assistance-as-Needed Support by an Ankle-Foot Orthosis for Patients with Foot Drop

Patients who suffer from foot drop have impaired gait pattern functions and a higher risk of stumbling and falling. Therefore, they are usually treated with an assistive device, a so-called ankle-foot orthosis. The support of the orthosis should be in accordance with the motor requirements of the patient and should only be provided when needed, which is referred to as assistance-as-needed. Thus, in this publication, an approach is presented to determine the assistance-as-needed support using musculoskeletal human models. Based on motion capture recordings of multiple subjects performing gaits at different speeds, a parameter study varying the optimal force of a reserve actuator representing the ankle-foot orthosis added in the musculoskeletal simulation is conducted. The results show the dependency of the simulation results on the selected optimal force of the reserve actuator but with a possible identification of the assistance-as-needed support required from the ankle-foot orthosis. The required increase in support due to the increasing severity of foot drop is especially demonstrated with the approach. With this approach, information for the required support of individual subjects can be gathered, which can further be used to derive the design of an ankle-foot orthosis that optimally assists the subjects.

"That's frustrating": Perceptions of ankle foot orthosis provision, use, and needs among people with cerebral palsy and caregivers

BACKGROUND

Cerebral palsy (CP) affects roughly 3 per 1000 births in the United States and is the most common pediatric developmental motor disability. Ankle foot orthoses (AFOs) are commonly prescribed to provide support and improve function for individuals with CP.

OBJECTIVES

The study objective was to evaluate the lived experiences of individuals with CP and their caregivers regarding AFO access, use, and priorities. We examined experiences around the perceived purpose of AFOs, provision process, current barriers to use, and ideas for future AFO design.

STUDY DESIGN

Secondary qualitative data analysis.

METHODS

Secondary data analysis was performed on semistructured focus groups that included 68 individuals with CP and 74 caregivers. Of the focus group participants, 66 mentioned AFOs (16 individuals with CP and 50 caregivers). Deidentified transcripts were analyzed using inductive coding, and the codes were consolidated into themes.

RESULTS

Four themes emerged: 1) AFO provision is a confusing and lengthy process, 2) participants want more information during AFO provision, 3) AFOs are uncomfortable and difficult to use, and 4) AFOs can benefit mobility and independence. Caregivers and individuals with CP recommended ideas such as 3D printing orthoses and education for caregivers on design choices to improve AFO design and provision.

CONCLUSIONS

Individuals with CP and their caregivers found the AFO provision process frustrating but highlight that AFOs support mobility and participation. Further opportunities exist to support function and participation of people with CP by streamlining AFO provision processes, creating educational materials, and improving AFO design for comfort and ease of use.

Passive Articulated and Non-Articulated Ankle-Foot Orthoses for Gait Rehabilitation: A Narrative Review

The aim of this work was to study the different types of passive articulated and non-articulated ankle-foot orthoses for gait rehabilitation in terms of working principles, control mechanisms, features, and limitations, along with the recent clinical trials on AFOs. An additional aim was to categorize them to help engineers and orthotists to develop novel designs based on this research. Based on selected keywords and their composition, a search was performed on the ISI Web of Knowledge, Google Scholar, Scopus, and PubMed databases from 1990 to 2022. Forty-two studies met the eligibility criteria, which highlighted the commonly used types and recent development of passive articulated and non-articulated ankle-foot orthoses for foot drop. Orthotists and engineers may benefit from the information obtained from this review article by enhancing their understanding of the challenges in developing an AFO that meets all the requirements in terms of ease of use, freedom of movement, and high performance at a relatively low cost.

Polymer-Based Additive Manufacturing for Orthotic and Prosthetic Devices: Industry Outlook in Canada

The conventional manufacturing methods for fabricating orthotic and prosthetic (O&P) devices have been in practice for a very long time. Recently, O&P service providers have started exploring different advanced manufacturing techniques. The objective of this paper is to perform a mini review on recent progress in the use of polymer-based additive manufacturing (AM) for O&P devices and to gather insights from the O&P professionals on the current practices and technologies and on the prospect of using AM techniques in this field. First, scientific articles on AM for O&P devices were studied. Then, twenty-two (22) interviews were conducted with O&P professionals from Canada. The primary focus was on five key areas: cost, material, design and fabrication efficiency, structural strength, functionality, and patient satisfaction. The cost of manufacturing the O&P devices using AM techniques is lower as compared to the conventional methods. O&P professionals expressed their concern over the materials and structural strength of the 3D-printed prosthetic devices. Published articles report comparable functionality and patient satisfaction for both O&P devices. AM also greatly improves design and fabrication efficiency. However, due to a lack of qualification standards for 3D printed O&P devices, 3D printing is being embraced more slowly in the O&P business than in other industries.

Comparison of five different methodologies for evaluating ankle-foot orthosis stiffness

BACKGROUND

The mechanical properties of an ankle-foot orthosis (AFO) play an important role in the gait mechanics of the end user. However, testing methodologies for evaluating these mechanical properties are not standardized. The purpose of this study was to compare five different evaluation frameworks to assess AFO stiffness.

METHOD

The same 13 carbon composite AFOs were tested with five different methods. Four previously reported custom test fixtures (the BRUCE, KST, SMApp, and EMPIRE) rotated an AFO into dorsiflexion about a defined axis in the sagittal plane. The fifth method involved quasi-static deflection of AFOs into dorsiflexion by hanging weights (HW) from the footplate. AFO rotational stiffness was calculated as the linear fit of the AFO resistive torque and angular deflection. Differences between methods were assessed using descriptive statistics and a repeated measures Friedman with post-hoc Bonferroni-Holm adjusted Wilcoxon signed-rank tests.

RESULTS

There were significant differences in measured AFO stiffnesses between test methods. Specifically, the BRUCE and HW methods measured lower stiffness than both the EMPIRE and the KST. Stiffnesses measured by the SMApp were not significantly different than any test method. Stiffnesses were lowest in the HW method, where motion was not constrained to a single plane. The median difference in absolute AFO stiffness across methods was 1.03 Nm/deg with a range of [0.40 to 2.35] Nm/deg. The median relative percent difference, measured as the range of measured stiffness from the five methods over the average measured stiffness was 62% [range 13% to 156%]. When the HW method was excluded, the four previously reported test fixtures produced a median difference in absolute AFO stiffness of 0.52 [range 0.38 to 2.17] Nm/deg with a relative percent difference between the methods of 27% [range 13% to 89%].

CONCLUSIONS

This study demonstrates the importance of developing mechanical testing standards, similar to those that exist for lower limb prosthetics. Lacking standardization, differences in methodology can result in large differences in measured stiffness, particularly for different constraints on motion. Non-uniform measurement practices may limit the clinical utility of AFO stiffness as a metric in AFO prescription and future research.

Advances in additive manufacturing processes and their use for the fabrication of lower limb prosthetic devices

INTRODUCTION

Traditional methods of prosthesis fabrication are not efficient and user centric and are made for common purposes without focusing on individual demands of user which leads to rejection of prosthesis for long-term use. Utilizing advanced additive manufacturing techniques for fabrication of prosthesis makes the development process user centric and covers all the user demands thus providing better fit, comfort, and more stable gait rehabilitation for the user.

AREAS COVERED

The articles reporting fabrication of lower limb prosthesis and its socket are included in the study. Standard fabrication and additive manufacturing method are both systematically assessed by the reviewers. The review also covers the advanced methods of additive manufacturing that are presently being used for fabrication of rehabilitation devices.

EXPERT OPINION

Additive manufacturing method of fabrication of prosthesis provides more flexibility for manufacturing prosthesis parts as per demand of the user. The fabrication method takes into account the residual limb and thus makes the prosthesis user-specific providing better comfort and fit.

Computational modelling of ankle-foot orthosis to evaluate spatially asymmetric structural stiffness: Importance of geometric nonlinearity

An ankle-foot orthosis (AFO) constructed as a single piece of isotropic elastic material is a commonly used assistive device that provides stability to the ankle joint of patients with spastic diplegic cerebral palsy. The AFO has asymmetric stiffness that restricts plantarflexion during the swing phase while it is flexible to allow dorsiflexion during the stance phase with a large deflection, including buckling originating from geometric nonlinearity. However, its mechanical implications have not been sufficiently investigated. This study aims to develop a computational model of an AFO considering geometric nonlinearity and examine AFO stiffness asymmetry during plantarflexion and dorsiflexion using physical experiments. Three-dimensional AFO mechanics with geometric nonlinearities were expressed using corotational triangle-element formulations that obeyed Kirchhoff-Love plate theory. Computational load tests for plantarflexion and dorsiflexion, using idealised AFOs with two different ankle-region designs (covering or not covering the apexes of the malleoli), showed that plantarflexion moment-ankle angle relationships were linear and dorsiflexion moment-ankle angle relationships were nonlinear; increases in dorsiflexion led to negative apparent stiffness of the AFO. Both ankle-region designs resisted both plantarflexion and dorsiflexion, and out-of-plane elastic energy was locally concentrated on the lateral side, resulting in large deflections during dorsiflexion. These findings give insight into appropriate AFO design from a mechanical viewpoint by characterising three-dimensional structural asymmetry and geometric nonlinearity.

Parametric equations to study and predict lower-limb joint kinematics and kinetics during human walking and slow running on slopes

Comprehensive data sets for lower-limb kinematics and kinetics during slope walking and running are important for understanding human locomotion neuromechanics and energetics and may aid the design of wearable robots (e.g., exoskeletons and prostheses). Yet, this information is difficult to obtain and requires expensive experiments with human participants in a gait laboratory. This study thus presents an empirical mathematical model that predicts lower-limb joint kinematics and kinetics during human walking and running as a function of surface gradient and stride cycle percentage. In total, 9 males and 7 females (age: 24.56 ± 3.16 years) walked at a speed of 1.25 m/s at five surface gradients (-15%, -10%, 0%, +10%, +15%) and ran at a speed of 2.25 m/s at five different surface gradients (-10%, -5%, 0%, +5%, +10%). Joint kinematics and kinetics were calculated at each surface gradient. We then used a Fourier series to generate prediction equations for each speed's slope (3 joints x 5 surface gradients x [angle, moment, mechanical power]), where the input was the percentage in the stride cycle. Next, we modeled the change in value of each Fourier series' coefficients as a function of the surface gradient using polynomial regression. This enabled us to model lower-limb joint angle, moment, and power as functions of the slope and as stride cycle percentages. The average adjusted R2 for kinematic and kinetic equations was 0.92 ± 0.18. Lastly, we demonstrated how these equations could be used to generate secondary gait parameters (e.g., joint work) as a function of surface gradients. These equations could be used, for instance, in the design of exoskeletons for walking and running on slopes to produce trajectories for exoskeleton controllers or for educational purposes in gait studies.

Replicating and redesigning ankle-foot orthoses with 3D printing for children with Charcot-Marie-Tooth disease

BACKGROUND

Children with the most common inherited neuropathy, Charcot-Marie-Tooth disease (CMT), are often prescribed ankle-foot orthoses (AFOs) to improve walking ability and prevent falls by reducing foot drop, postural instability, and other gait impairments. These externally worn assistive devices are traditionally custom-made using thermoplastic vacuum forming. This labour-intensive manufacturing process often results in AFOs which are cumbersome due to limited design options, and are associated with low acceptability, discomfort, and suboptimal impact on gait. The aim of this study was to determine how 3D printing can be used to replicate and redesign AFOs in children with CMT.

METHODS

Traditional AFOs, 3D printed replica AFOs (same design as traditional AFOs), 3D printed redesigned AFOs and a shoes only control condition were compared in 12 children with CMT. 3D printed AFOs were manufactured using material extrusion in Nylon-12. 3D gait analysis (temporal-spatial, kinematic, kinetic), in-shoe pedobarography and self-reported satisfaction were used to compare conditions. The primary kinematic and kinetic outcome measures were maximum ankle dorsiflexion in swing and maximum ankle dorsiflexor moment in loading response, to capture foot drop and an absent of heel rocker.

RESULTS

The 3D printed replica AFOs were comparable to traditional AFOs for all outcomes. The 3D printed replica AFOs improved foot position at initial contact and during loading response and significantly reduced pressure beneath the whole foot, rearfoot and forefoot compared to the shoes only. The 3D printed redesigned AFOs produced a device that was significantly lighter (mean -35.2, SD 13.3%), and normalised maximum ankle dorsiflexor moment in loading response compared to shoes only and traditional AFOs.

SIGNIFICANCE

3D printing can be used to replicate traditional handmade AFOs and to redesign AFOs to produce a lighter device with improved biomechanics by incorporating novel design features.

Design principles, manufacturing and evaluation techniques of custom dynamic ankle-foot orthoses: a review study

Ankle-Foot Orthoses (AFO) can be prescribed to allow drop-foot patients to restore a quasi-normal gait pattern. Standard off-the-shelf AFOs are cost-effective solutions to treat most patients with foot and ankle weakness, but these devices have several limitations, especially in terms of comfort. Therefore, custom AFOs are increasingly adopted to address drop-foot when standard solutions are not adequate. While the solid ones are the most common type of AFO, providing full stability and strong resistance to ankle plantarflexion, passive dynamic AFOs (PD-AFOs) represent the ideal solution for patients with less severe ankle weakness. PD-AFOs have a flexible calf shell, which can bend during the stance phase of walking and absorb energy that can be released to support the limb in the push-off phase. The aim of this review is to assess the state-of-the-art and identify the current limitations of PD-AFOs. An extensive literature review was performed in Google Scholar to identify all studies on custom PD-AFOs. Only those papers reporting on custom PD-AFOs were included in the review. Non peer-reviewed papers, abstract shorter than three pages, lecture notes and thesis dissertations were excluded from the analysis. Particular attention was given to the customization principles and the mechanical and functional tests. For each topic, the main results from all relevant papers are reported and summarized herein. There were 75 papers that corresponded to the search criteria. These were grouped according to the following macro-topics: 16 focusing on scanning technologies and geometry acquisition; 14 on customization criteria; 19 on production techniques; 16 on mechanical testing, and 33 on functional testing. According to the present review, design and production of custom PD-AFOs are becoming increasingly feasible due to advancements in 3D scanning techniques and additive manufacturing. In general, custom PD-AFOs were shown to provide better comfort and improved spatio-temporal parameters with respect to standard solutions. However, no customization principle to adapt PD-AFO stiffness to the patient's degree of ankle impairment or mechanical/functional demand has thus far been proposed.

Design of a segmented custom ankle foot orthosis with custom-made metal strut and 3D-printed footplate and calf shell

BACKGROUND

3D-printing is a potential manufacturing process for optimizing the design and manufacture of ankle foot orthosis (AFOs). The feasibility of an AFO with interchangeable strut that is suitable for 3D-printing is created and evaluated.

OBJECTIVE

A segmented AFO with 3D-printed custom footplate and calf shell connected by a custom-made strut is studied.

STUDY DESIGN

The duration of a healthy subject wearing the 3D-printed segmented AFO in daily activities is used to evaluate the feasibility and durability to integrate 3D-printed AFOs into orthotics practice.

TECHNIQUE

The 3D-scanning of a patient's leg is first conducted. The scanned 3D surface is modified by creating the clearance around bony prominences and trimlines for the footplate and calf shell. The footplate has a custom-shaped inside to match with the foot and a standard shape outside at the top to match and connect with the strut. For the calf shell, the inside shape is custom fit with the shank and the outside shape is standard to connect with the strut. Material extrusion is the 3D-printing process selected. Tree-like support structures are used to avoid the use of soluble support material and to eliminate the risk of residual chemical solvent in the orthosis.

RESULTS

The segmented AFO with material extrusion footplate and calf shell was tested in a healthy subject with an active lifestyle, offering comfort, and stability for over 4 months without breakage.

CONCLUSIONS

This segmented AFO is durable, requires short 3D-printing time, and enables the quick adjustment of bending stiffness via an interchangeable strut design.

Exoskeleton robots for lower limb assistance: A review of materials, actuation, and manufacturing methods

The field of robot-assisted physical rehabilitation and robotics technology for providing support to the elderly population is rapidly evolving. Lower limb robot aided rehabilitation and assistive technology have been a focus for the engineering community during the last three decades as several robotic lower limb exoskeletons have been proposed in the literature as well as some being commercially available. Numerous manufacturing techniques and materials have been developed for lower limb exoskeletons during the last two decades, resulting in the design of a variety of robot exoskeletons for gait assistance for elderly and disabled people. One of the most important aspects of developing exoskeletons is the selection of the most appropriate proper material. The material selection strongly influences the overall weight and performance of the exoskeleton robot. The most suitable fabrication method for material is also an important parameter for the development of lower limb robot exoskeletons. In addition to the materials and manufacturing methods, the actuation method plays a vital role in the development of these robot exoskeletons. Even though various materials, manufacturing methods and actuators are reported in the literature for these lower limb robot exoskeletons, there are still avenues of improvement in these three domains. In this review, we have examined various lower limb robotic exoskeletons, concentrating on the three main aspects of material, manufacturing, and actuation. We have focused on the advantages and drawbacks of various materials and manufacturing practices as well as actuation methods. A discussion on future directions of research is provided for the engineering community covering the material, manufacturing and actuation methods.

Advanced design and manufacturing of custom orthotics insoles based on hybrid Taguchi-response surface method

Herein, a machining strategy to fabricate custom orthotic insoles with high surface finish and wide fit tolerance is presented. CNC milling was used to machine ethylene-vinyl acetate (EVA) foam for insoles with various surface hardness, and the Taguchi-response surface method (TM-RSM) was adopted to optimize the parameters of the CNC milling process (cutting speed, feed rate, tool path strategy, and step over). EVA foam with varying surface hardness and the tolerance of the wide fit insoles corresponding to the surface roughness were analyzed. Subsequently, a mathematical model was established to determine the optimal CNC milling parameters for a standard milling cutter under dry coolants. The results of the six parameters corresponding to the mean values of surface roughness were initially examined using the signal-to-noise ratio of the Taguchi method (TM). The surface roughness obtained with the TM-RSM was up to 4.13% higher than that obtained with the TM. The EVA foam insole with a surface hardness of 50–60 HRC and a wide fit tolerance of 0.75 mm provided the ideal level of comfort and support for patients with diabetes. The results of this study demonstrated that CNC milling provided a better surface finish of orthotic shoe insoles than other methods, which can serve as guidance in the development of machining strategies for insoles made from EVA foam.

Application of non-contact scanning to forensic podiatry: A feasibility study

Foot impression evidence recovered from crime scenes can be available in the form of barefoot prints, sock-clad footprints, or as impressions within footwear. In some cases, suspects leave their footwear at the scene of the crime, and the insoles from the footwear can be important in linking a person to the footwear. The application of 3D data-collecting technology is becoming more and more popular within forensic science and has been used to recover footwear impression evidence. The present study is a feasibility study to discover if 3D data capturing devices can be applied to insoles; to capture the footprint impression for measurement using the Gunn method (a method used in forensic podiatry casework). Three different methods of data capture were conducted; Adobe Photoshop, MeshLab, and calipers used directly on the insole. Paired t-tests and Intraclass Correlation Coefficient (ICC) were conducted for all three data capture methods. Seven measurements used in this study were significantly different across all three methods. ICC scores were moderate to excellent for the Photoshop method, poor to good for the 3D method, and moderate to excellent for the Direct method.

Advances in Orthotic and Prosthetic Manufacturing: A Technology Review

In this work, the recent advances for rapid prototyping in the orthoprosthetic industry are presented. Specifically, the manufacturing process of orthoprosthetic aids are analysed, as thier use is widely extended in orthopedic surgery. These devices are devoted to either correct posture or movement (orthosis) or to substitute a body segment (prosthesis) while maintaining functionality. The manufacturing process is traditionally mainly hand-crafted: The subject's morphology is taken by means of plaster molds, and the manufacture is performed individually, by adjusting the prototype over the subject. This industry has incorporated computer aided design (CAD), computed aided engineering (CAE) and computed aided manufacturing (CAM) tools; however, the true revolution is the result of the application of rapid prototyping technologies (RPT). Techniques such as fused deposition modelling (FDM), selective laser sintering (SLS), laminated object manufacturing (LOM), and 3D printing (3DP) are some examples of the available methodologies in the manufacturing industry that, step by step, are being included in the rehabilitation engineering market-an engineering field with growth and prospects in the coming years. In this work we analyse different methodologies for additive manufacturing along with the principal methods for collecting 3D body shapes and their application in the manufacturing of functional devices for rehabilitation purposes such as splints, ankle-foot orthoses, or arm prostheses.

Evaluating additive manufacturing for the production of custom head supports: A comparison against a commercial head support under static loading conditions

The provision of wheelchair seating accessories, such as head supports, is often limited to the use of commercial products. Additive manufacturing has the potential to produce custom seating components, but there are very few examples of published work. This article reports a method of utilising 3D scanning, computer-aided design and additive manufacturing for the fabrication of a custom head support for a wheelchair. Three custom head supports, of the same shape, were manufactured in nylon using a continuous filament fabrication machine. The custom head supports were tested against an equivalent and widely used commercial head support using ISO 16840-3:2014. The head supports were statically loaded in two configurations, one modelling a posterior force on the inner rear surface and the other modelling a lateral force on the side. The posterior force resulted in failure of the supporting bracketry before the custom head support. A similar magnitude of forces was applied laterally for the custom and commercial head support. When the load was removed, the custom recovered to its original shape while the commercial sustained plastic deformation. The addition of a joint in the head support increased the maximum displacement, 128.6 mm compared to 71.7 mm, and the use of carbon fibre resulted in the head support sustaining a higher force at larger displacements, increase in 30 N. Based on the deformation and recovery characteristics, the results indicate that additive manufacturing could be an appropriate method to produce lighter weight, highly customised, cost-effective and safe head supports for wheelchair users.

Ankle-foot orthosis design between the tradition and the computerized perspectives

This study focuses on the drop foot case related to hyperthyroidism of the ankle joint resulting in the relaxation of the toes during walking. This condition requires treatment using an ankle-foot orthosis. Traditional orthosis techniques lack precision and depend on the skill of the fabricator. This research aims to make a bias in ankle-foot orthosis design and analysis methods, where a complete methodology of numerical design and testing has been proposed using advanced engineering software. A numerical model of the patient's foot was generated and used to design an ankle-foot orthosis model using SolidWorks. The designed model was mechanically analyzed by the finite element method using ANSYS Workbench 16.1 under different static and dynamic loading conditions. The ankle-foot orthosis model was numerically designed and analyzed before the manufacturing process. This is believed to reduce time and material loss and foster the use of numerical models in biomedical applications. This study suggests focusing on the design and analysis of orthoses according to the patient's measurements. This is expected to increase the comfort and raise the level of treatment. Numerical design methods also enable precise manufacturing using computerized devices such as three-dimensional printers.

A study on the efficacy of AFO stiffness prescriptions

PURPOSE

Ankle foot orthosis (AFO) stiffness is a key characteristic that determines how much support or restraint an AFO can provide. Thus, the goal of the current study is twofold: (1) to quantify AFO prescriptions for a group of patients; (2) to evaluate what impact these AFO have on the push-off phase.

METHOD

Six patients were included in the study. Three patients were prescribed an AFO for ankle support and three patients were prescribed an AFO for ankle and knee support. Two types of AFO - a traditional polypropylene AFO (AFOPP) and a novel carbon-selective laser sintered polyamide AFO (AFOPA), were produced for each patient. AFO ankle stiffness was measured in a dedicated test rig. Gait analysis was performed under shod and orthotic conditions.

RESULTS

Patient mass normalized AFOPP stiffness for ankle support ranged from 0.042 to 0.069 N·m·deg^-1·kg^-1, while for ankle and knee support it ranged from 0.081 to 0.127 N·m·deg^-1·kg^-1. On the group level, the ankle range of motion and mean ankle velocity in the push-off phase significantly decreased in both orthotic conditions, while peak ankle push-off power decreased non-significantly. Accordingly, on the group level, no significant improvements in walking speed were observed. However, after patient differentiation into good and bad responders it was found that in good responders peak ankle push-off power tended to be preserved and walking speed tended to increase.

CONCLUSIONS

Quantification of AFO stiffness may help to understand why certain orthotic interventions are successful (unsuccessful) and ultimately lead to better AFO prescriptions. Implications for rehabilitation AFO ankle stiffness is key characteristic that determines how much support or restraint an AFO can provide. In a typical clinical setting, AFO ankle stiffness is not quantified. AFO has to meet individual patient's biomechanical needs. More objective AFO prescription and more controlled AFO production methods are needed to increase AFO success rate.

The foot and ankle structures reveal emergent properties analogous to passive springs during human walking

An objective understanding of human foot and ankle function can drive innovations of bio-inspired wearable devices. Specifically, knowledge regarding how mechanical force and work are produced within the human foot-ankle structures can help determine what type of materials or components are required to engineer devices. In this study, we characterized the combined functions of the foot and ankle structures during walking by synthesizing the total force, displacement, and work profiles from structures distal to the shank. Eleven healthy adults walked at four scaled speeds. We quantified the ground reaction force and center-of-pressure displacement in the shank’s coordinate system during stance phase and the total mechanical work done by these structures. This comprehensive analysis revealed emergent properties of foot-ankle structures that are analogous to passive springs: these structures compressed and recoiled along the longitudinal axis of the shank, and performed near zero or negative net mechanical work across a range of walking speeds. Moreover, the subject-to-subject variability in peak force, total displacement, and work were well explained by three simple factors: body height, mass, and walking speed. We created a regression-based model of stance phase mechanics that can inform the design and customization of wearable devices that may have biomimetic or non-biomimetic structures.

Computational and experimental evaluation of the mechanical properties of ankle foot orthoses: A literature review

BACKGROUND

Ankle foot orthoses are external medical devices applied around the ankle joint area to provide stability to patients with neurological, muscular, and/or anatomical disabilities, with the aim of restoring a more natural gait pattern.

STUDY DESIGN

This is a literature review.

OBJECTIVES

To provide a description of the experimental and computational methods present in the current literature for evaluating the mechanical properties of the ankle foot orthoses.

METHODS

Different electronic databases were used for searching English-language articles realized from 1990 onward in order to select the newest and most relevant information available.

RESULTS

A total of 46 articles were selected, which describe the different experimental and computational approaches used by research groups worldwide.

CONCLUSION

This review provides information regarding processes adopted for the evaluation of mechanical properties of ankle foot orthoses, in order to both improve their design and gain a deeper understanding of their clinical use. The consensus drawn is that the best approach would be represented by a combination of advanced computational models and experimental techniques, capable of being used to optimally mimic real-life conditions.

CLINICAL RELEVANCE

In literature, several methods are described for the mechanical evaluation of ankle foot orthoses (AFOs); therefore, the goal of this review is to guide the reader to use the best approach in the quantification of the mechanical properties of the AFOs and to help gaining insight in the prescription process.

A validated computational framework to evaluate the stiffness of 3D printed ankle foot orthoses

The purpose of this study was to create and validate a standardized framework for the evaluation of the ankle stiffness of two designs of 3D printed ankle foot orthoses (AFOs). The creation of four finite element (FE) models allowed patient-specific quantification of the stiffness and stress distribution over their specific range of motion during the second rocker of the gait. Validation was performed by comparing the model outputs with the results obtained from a dedicated experimental setup, which showed an overall good agreement with a maximum relative error of 10.38% in plantarflexion and 10.66% in dorsiflexion. The combination of advanced computer modelling algorithms and 3D printing techniques clearly shows potential to further improve the manufacturing process of AFOs.

Design of a Low Profile, Unpowered Ankle Exoskeleton That Fits Under Clothes: Overcoming Practical Barriers to Widespread Societal Adoption

Here, we present the design of a novel unpowered ankle exoskeleton that is low profile, lightweight, quiet, and low cost to manufacture, intrinsically adapts to different walking speeds, and does not restrict non-sagittal joint motion; while still providing assistive ankle torque that can reduce demands on the biological calf musculature. This paper is an extension of the previously-successful ankle exoskeleton concept by Collins, Wiggin, and Sawicki. We created a device that blends the torque assistance of the prior exoskeleton with the form-factor benefits of clothing. Our design integrates a low profile under-the-foot clutch and a soft conformal shank interface, coupled by an ankle assistance spring that operates in parallel with the user's calf muscles. We fabricated and characterized technical performance of a prototype through benchtop testing and then validated device functionality in two gait analysis case studies. To our knowledge, this is the first ankle plantarflexion assistance exoskeleton that could be feasibly worn under typical daily clothing, without restricting ankle motion, and without components protruding substantially from the shoe, leg, waist, or back. Our new design highlights the potential for performance-enhancing exoskeletons that are inexpensive, unobtrusive, and can be used on a wide scale to benefit a broad range of individuals throughout society, such as the elderly, individuals with impaired plantarflexor muscle strength, or recreational users. In summary, this paper demonstrates how an unpowered ankle exoskeleton could be redesigned to more seamlessly integrate into daily life, while still providing performance benefits for common locomotion tasks.

Feasibility of designing, manufacturing and delivering 3D printed ankle-foot orthoses: a systematic review

Background

Ankle-foot orthoses (AFO) are prescribed to manage difficulty walking due to foot drop, bony foot deformities and poor balance. Traditional AFOs are handmade using thermoplastic vacuum forming which provides limited design options, is labour-intensive and associated with long wait times. 3D printing has the potential to transform AFO production and health service delivery. The aim of this systematic review was to determine the feasibility of designing, manufacturing and delivering customised 3D printed AFOs by evaluating the biomechanical outcomes, mechanical properties and fit of 3D printed compared to traditionally manufactured AFOs.

Method

Electronic databases were searched from January 1985 to June 2018 according to terms related to 3D printing and AFOs. Studies of any design from healthy or pathological populations of any age were eligible for inclusion. Studies must have investigated the effect of customised 3D printed AFOs using any 3D printing technique on outcomes related to walking ability, biomechanical function, mechanical properties, patient comfort, pain and disability. Any other orthotic type or AFOs without a 3D printed calf and foot section were excluded. The quality of evidence was assessed using the GRADE process.

Results

Eleven studies met the eligibility criteria evaluating 3D printed AFOs in healthy adults, and adults and children with unilateral foot drop from a variety of conditions. 3D printing was used to replicate traditional AFOs and develop novel designs to optimise the stiffness properties or reduce the weight and improve the ease of use of the AFO. 3D printed custom AFOs were found to be comparable to traditional custom AFOs and prefabricated AFOs in terms of temporal-spatial parameters. The mechanical stiffness and energy dissipation of 3D printed AFOs were found to be similar to prefabricated carbon-fibre AFOs. However, the sample sizes were small (n = 1 to 8) and study quality was generally low.

Conclusion

The biomechanical effects and mechanical properties of 3D printed AFOs were comparable to traditionally manufactured AFOs. Developing novel AFO designs using 3D printing has many potential benefits including stiffness and weight optimisation to improve biomechanical function and comfort.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0321-6) contains supplementary material, which is available to authorized users.

AMB2018-04: Benchmark Physical Property Measurements for Powder Bed Fusion Additive Manufacturing of Polyamide 12

Laser sintering (LS) of polyamide 12 (PA12) is increasingly being adopted for industrial production of end-use parts, yet the complexity of this process coupled with the lack of organized, rigorous, publicly available process-structure-physical property datasets exposes manufacturers and customers to risks of unacceptably poor part quality and high costs. Although an extensive scientific literature has been developed to address some of these concerns, results are distributed among numerous reports based on different machines, materials, process parameters, and users. In this study, a single commercially important LS PA12 feedstock has been processed along four build dimensions of a modern production LS machine, characterized by a wide range of physical techniques, and compared to the same material formed by conventional melt processing. Results are discussed in the context of the literature, offering novel insights including distributions of particle size and shape, localization of semicrystalline phase changes due to LS processing, effect of chemical aging on melt viscosity, porosity orientation relative to LS build axes, and microstructural effects on tensile properties and failure mechanisms. The resulting datasets will be made publicly available to modelers and practitioners for the purpose of improving certifiability and repeatability of end-use parts manufactured by LS.

Feasibility study applying a parametric model as the design generator for 3D-printed orthosis for fracture immobilization

Background

Applying 3D printing technology for the fabrication of custom-made orthoses provides significant advantages, including increased ventilation and lighter weights. Currently, the design of such orthoses is most often performed in the CAD environment, but creating the orthosis model is a time-consuming process that requires significant CAD experience. This skill gap limits clinicians from applying this technology in fracture treatment. The purpose of this study is to develop a parametric model as the design generator for 3D–printed orthoses for an inexperienced CAD user and to evaluate its feasibility and ease of use via a training and design exercise.

Results

A set of automatic steps for orthosis modeling was developed as a parametric model using the Visual Programming Language in the CAD environment, and its interface and workflow were simplified to reduce the training period. A quick training program was formulated, and 5 participants from a nursing school completed the training within 15 mins. They verified its feasibility in an orthosis design exercise and designed 5 orthoses without assistance within 8 to 20 mins. The few faults and program errors that were observed in video analysis of the exercise showed improvable weaknesses caused by the scanning quality and modeling process.

Conclusions

Compared to manual modeling instruction, this study highlighted the feasibility of using a parametric model for the design of 3D–printed orthoses and its greater ease of use for medical personnel compared to the CAD technique. The parametric model reduced the complex process of orthosis design to a few minutes, and a customized interface and training program accelerated the learning period. The results from the design exercise accurately reflect real-world situations in which an inexperienced user utilizes a generator as well as demonstrate the utility of the parametric model approach and strategy for training and interfacing.

The effects of prosthetic foot stiffness on transtibial amputee walking mechanics and balance control during turning

BACKGROUND

Little evidence exists regarding how prosthesis design characteristics affect performance in tasks that challenge mediolateral balance such as turning. This study assesses the influence of prosthetic foot stiffness on amputee walking mechanics and balance control during a continuous turning task.

METHODS

Three-dimensional kinematic and kinetic data were collected from eight unilateral transtibial amputees as they walked overground at self-selected speed clockwise and counterclockwise around a 1-meter circle and along a straight line. Subjects performed the walking tasks wearing three different ankle-foot prostheses that spanned a range of sagittal- and coronal-plane stiffness levels.

FINDINGS

A decrease in stiffness increased residual ankle dorsiflexion (10-13°), caused smaller adaptations (<5°) in proximal joint angles, decreased residual and increased intact limb body support, increased residual limb propulsion and increased intact limb braking for all tasks. While changes in sagittal-plane joint work due to decreased stiffness were generally consistent across tasks, effects on coronal-plane hip work were task-dependent. When the residual limb was on the inside of the turn and during straight-line walking, coronal-plane hip work increased and coronal-plane peak-to-peak range of whole-body angular momentum decreased with decreased stiffness.

INTERPRETATION

Changes in sagittal-plane kinematics and kinetics were similar to those previously observed in straight-line walking. Mediolateral balance improved with decreased stiffness, but adaptations in coronal-plane angles, work and ground reaction force impulses were less systematic than those in sagittal-plane measures. Effects of stiffness varied with the residual limb inside versus outside the turn, which suggests that actively adjusting stiffness to turn direction may be beneficial.

Passive-dynamic ankle-foot orthosis replicates soleus but not gastrocnemius muscle function during stance in gait: Insights for orthosis prescription

BACKGROUND

Passive-dynamic ankle-foot orthosis characteristics, including bending stiffness, should be customized for individuals. However, while conventions for customizing passive-dynamic ankle-foot orthosis characteristics are often described and implemented in clinical practice, there is little evidence to explain their biomechanical rationale.

OBJECTIVES

To develop and combine a model of a customized passive-dynamic ankle-foot orthosis with a healthy musculoskeletal model and use simulation tools to explore the influence of passive-dynamic ankle-foot orthosis bending stiffness on plantar flexor function during gait.

STUDY DESIGN

Dual case study.

METHODS

The customized passive-dynamic ankle-foot orthosis characteristics were integrated into a healthy musculoskeletal model available in OpenSim. Quasi-static forward dynamic simulations tracked experimental gait data under several passive-dynamic ankle-foot orthosis conditions. Predicted muscle activations were calculated through a computed muscle control optimization scheme.

RESULTS

Simulations predicted that the passive-dynamic ankle-foot orthoses substituted for soleus but not gastrocnemius function. Induced acceleration analyses revealed the passive-dynamic ankle-foot orthosis acts like a uniarticular plantar flexor by inducing knee extension accelerations, which are counterproductive to natural knee kinematics in early midstance.

CONCLUSION

These passive-dynamic ankle-foot orthoses can provide plantar flexion moments during mid and late stance to supplement insufficient plantar flexor strength. However, the passive-dynamic ankle-foot orthoses negatively influenced knee kinematics in early midstance.

CLINICAL RELEVANCE

Identifying the role of passive-dynamic ankle-foot orthosis stiffness during gait provides biomechanical rationale for how to customize passive-dynamic ankle-foot orthoses for patients. Furthermore, these findings can be used in the future as the basis for developing objective prescription models to help drive the customization of passive-dynamic ankle-foot orthosis characteristics.

A rapid and intelligent designing technique for patient-specific and 3D-printed orthopedic cast

Background

Two point four out of 100 people suffer from one or more fractures in the course of average lifetimes. Traditional casts are featured as cumbersome structures that result in high risk of cutaneous complications. Clinical demands for developing a hygienic cast have gotten more and more attention. 3D printing technique is rapidly growing in the fabrication of custom-made rehabilitation tools. The objective of this study is to develop a rapid and intelligent modeling technique for developing patient-specific and hygienic orthopedic casts produced by 3D printing technologies.

Results

A cast model is firstly created from a patient’s image to develop patient-specific features. A unique technique to creating geometric reference has been developed to perform detail modeling cast. The cast is modeled as funnel-shaped geometry to create smooth edges to prevent bruises from mild movements of injured limbs. Surface pattern includes ventilation structure and opening gap for hygienic purpose and wearing comfort. The cast can be adjusted to accommodate swelling from injured limbs during treatment. Finite element analysis (FEA) is employed to validate the mechanical performance of the cast structure and identify potential risk of the structural collapse due to concentrated stresses. The cast is fabricated by 3D printing technology using approval material.

Conclusions

The 3D-printed prototype is featured as super lightweight with 1/10 of weight in compared with traditional alternatives. Medical technicians with few experiences can design cast within 20 min using the proposed technique. The image-based design minimizes the distortion during healing process because of the best fit geometry. The highly ventilated structure develops hygienic benefits on reducing the risk of cutaneous complications and potentially improve treatment efficacy and increase patients’ satisfactions.

The influence of passive-dynamic ankle-foot orthosis bending axis location on gait performance in individuals with lower-limb impairments

BACKGROUND

Passive-dynamic ankle-foot orthoses are commonly prescribed to augment impaired ankle muscle function, however their design and prescription are largely qualitative. One design includes a footplate and cuff, and flexible strut connecting the two. During gait, deflection occurs along the strut, with the greatest deflection at a central bending axis. The vertical location of the axis can affect lower extremity biomechanics. The goal of this study was to investigate the influence of bending axis location on gait performance.

METHODS

For thirteen participants with unilateral ankle muscle weakness, an additive manufacturing framework was used to fabricate passive-dynamic ankle-foot orthosis struts with central and off-center bending axes. Participants walked overground while electromyographic, kinetic and kinematic data were collected for three different bending axes: proximal (high), central (middle) and distal (low), and the participants indicated their order of bending axis preference after testing. Gait measures and preference effect sizes were examined during six regions of the gait cycle.

FINDINGS

A few differences between bending axes were observed: in the first double-leg support peak plantarflexion angle, peak dorsiflexion moment and positive hip work, in the early single-leg support peak knee extension moment and positive ankle and knee work, and in the late single-leg support gastrocnemius activity and vertical ground reaction force impulse. In addition, preference was strongly related to various gait measures.

INTERPRETATION

Despite the observed statistical differences, altering bending axis location did not produce large and consistent changes in gait performance. Thus, individual preference and comfort may be more important factors guiding prescription.

Potential of modeling and simulations of bioengineered devices: Endoprostheses, prostheses and orthoses

Modeling and simulation of prosthetic devices are the new tools investigated for the production of total customized prostheses. Computational simulations are used to evaluate the geometrical and material designs of a device while assessing its mechanical behavior. Data acquisition through magnetic resonance imaging, computed tomography or laser scanning is the first step that gives information about the human anatomical structures; a file format has to be elaborated through computer-aided design software. Computer-aided design tools can be used to develop a device that respects the design requirements as, for instance, the human anatomy. Moreover, through finite element analysis software and the knowledge of loads and conditions the prostheses are supposed to face in vivo, it is possible to simulate, analyze and predict the mechanical behavior of the prosthesis and its effects on the surrounding tissues. Moreover, the simulations are useful to eventually improve the design (as geometry, materials, features) before the actual production of the device. This article presents an extensive analysis on the use of finite element modeling for the design, testing and development of prosthesis and orthosis devices.

Experimental and computational analysis of composite ankle-foot orthosis

Carbon fiber (CF) ankle-foot orthoses (AFOs) can improve gait by increasing ankle plantar-flexor power and improving plantar-flexor ankle joint moment and energy efficiency compared with posterior leaf spring AFOs made of thermoplastic. However, fabricating a CF AFO to optimize the performance of the individual user may require multiple AFOs and expensive fabrication costs. Finite element analysis (FEA) models were developed to predict the mechanical behavior of AFOs in this study. Three AFOs, two made of CF composite material and one made of thermoplastic material, were fabricated and then mechanically tested to produce force-displacement data. The FEA models were validated by comparing model predictions with mechanical testing data performed under the same loading and boundary conditions. The actual mechanical testing demonstrated that CF performs better than thermoplastic. The simulation results showed that FEA models produced accurate predictions for both types of orthoses. The relative error of the energy return ratio predicted by the CF AFO FEA model developed in this study is less than 3%. We conclude that highly accurate FEA models will allow orthotists to improve CF AFO fabrication without wasting resources (time and money) on trial and error fabrications that are expensive and do not consistently improve AFO and user performance.

COMPUTER AIDED DESIGN AND FABRICATION OF A CUSTOM ARTICULATED ANKLE FOOT ORTHOSIS

Traditional design and manufacturing methods of ankle foot orthosis (AFO) involve manual techniques e.g., casting and molding of the limbs and often depend on trial and error. Three-dimensional scanning allows computer aided design (CAD) tools to be incorporated, however, both approaches rely on the external model of the limb. To design AFO with articulated joint, precise alignment of mechanical and anatomical joint axes is imperative. It is difficult to infer joint axis from external model as it is partially specified by the skeletal structure. In this article, a computer integrated design approach of an articulated AFO has been demonstrated. CAD model of the AFO was developed for a healthy subject's left leg based on the 3D models of skeleton and soft tissue of the limb. Components of the AFO were fabricated by rapid prototyping and CNC machining. The design approach is faster than the traditional techniques and also facilitates exact positioning of articulated ankle joint. The gait analysis indicates that the subject's ankle had to overcome lesser resistance with the custom made AFO compared to a pre-fabricated AFO. Simultaneous viewing of exterior and skeletal geometry might help the clinicians modify the design to enhance performance of the orthotic.

Biomechanics of uphill walking using custom ankle-foot orthoses of three different stiffnesses

Ankle-foot orthoses (AFOs) can provide support and improve walking ability in individuals with plantarflexor weakness. Passive-dynamic AFO stiffness can be optimized for over-ground walking, however little research exists for uphill walking, when plantarflexor contributions are key.

PURPOSE

Compare uphill walking biomechanics (1) between dynamic AFO users and able-bodied control subjects. (2) between injured and sound limbs (3) across different AFO stiffnesses.

METHODS

Twelve patients with unilateral limb-salvage and twelve matched, able-bodied controls underwent biomechanical gait analysis when walking up a 10° incline. Three AFO stiffnesses were tested in the patient group: Nominal (clinically prescribed), Compliant (20% less stiff), and Stiff (20% more stiff).

RESULTS AND DISCUSSION

AFO users experienced less ankle motion and power generation, lower knee extensor moments, and greater hip flexion and power generation than controls during uphill walking. Despite these deviations, they walked at equivalent self-selected velocities and stride lengths. Asymmetries were present at the ankle and knee with decreased ankle motion and power, and lower knee extensor moments on the AFO limb. Stiffer AFOs increased knee joint flexion but a 40% range in AFO stiffness had few other effects on gait. Therefore, a wide range of clinically prescribed AFO stiffnesses may adequately assist uphill walking.

How does ankle-foot orthosis stiffness affect gait in patients with lower limb salvage?

BACKGROUND

Ankle-foot orthoses (AFOs) are commonly prescribed during rehabilitation after limb salvage. AFO stiffness is selected to help mitigate gait deficiencies. A new custom dynamic AFO, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), is available to injured service members but prescription guidelines are limited.

QUESTIONS/PURPOSES

In this study we ask (1) does dynamic AFO stiffness affect gait parameters such as joint angles, moments, and powers; and (2) can a given dynamic AFO stiffness normalize gait mechanics to noninjured control subjects?

METHODS

Thirteen patients with lower limb salvage (ankle arthrodesis, neuropathy, foot/ankle reconstruction, etc) after major lower extremity trauma and 13 control subjects who had no lower extremity trauma and wore no orthosis underwent gait analysis at a standardized speed. Patients wore their custom IDEO with posterior struts of three different stiffnesses: nominal (clinically prescribed stiffness), compliant (20% less stiff), and stiff (20% stiffer). Joint angles, moments, powers, and ground reaction forces were compared across the varying stiffnesses of the orthoses tested and between the patient and control groups.

RESULTS

An increase in AFO compliance resulted in 20% to 26% less knee flexion relative to the nominal (p = 0.003) and stiff (p = 0.001) conditions, respectively. Ankle range of motion and power generation were, on average, 56% (p < 0.001) and 63% (p < 0.001), respectively, less than controls as a result of the relatively fixed ankle position.

CONCLUSIONS

Patients with limb salvage readily adapted to different dynamic AFO stiffnesses and demonstrated few biomechanical differences among conditions during walking. None of the stiffness conditions normalized gait to controls.

CLINICAL RELEVANCE

The general lack of differences across a 40% range of strut stiffness suggests that orthotists do not need to invest large amounts of time identifying optimal device stiffness for patients who use dynamic AFOs for low-impact activities such as walking. However, choosing a stiffer strut may more readily translate to higher-impact activities and offer less chance of mechanical failure.

The influence of ankle-foot orthosis stiffness on walking performance in individuals with lower-limb impairments

BACKGROUND

Passive-dynamic ankle-foot orthoses utilize stiffness to improve gait performance through elastic energy storage and return. However, the influence of ankle-foot orthosis stiffness on gait performance has not been systematically investigated, largely due to the difficulty of manufacturing devices with precisely controlled stiffness levels. Additive manufacturing techniques such as selective laser sintering have been used to successfully manufacture ankle-foot orthoses with controlled stiffness levels. The purpose of this study was to use passive-dynamic ankle-foot orthoses manufactured with selective laser sintering to identify the influence of orthosis stiffness on walking performance in patients with lower-limb neuromuscular and musculoskeletal impairments.

METHODS

Thirteen subjects with unilateral impairments were enrolled in this study. For each subject, one passive-dynamic ankle-foot orthosis with stiffness equivalent to the subject's clinically prescribed carbon fiber orthosis, one 20% more compliant and one 20% more stiff, were manufactured using selective laser sintering. Three-dimensional kinematic and kinetic data and electromyographic data were collected from each subject while they walked overground with each orthosis at their self-selected velocity and a controlled velocity.

FINDINGS

As the orthosis stiffness decreased, ankle range of motion and medial gastrocnemius activity increased while the knee became more extended throughout stance. Minimal changes in other kinematic, kinetic and electromyographic quantities were observed.

INTERPRETATION

Subjects effectively compensated for changes in ankle-foot orthosis stiffness with altered gastrocnemius activity, and the stiffness levels analyzed in this study had a minimal effect on overall walking performance.

The use of a low cost 3D scanning and printing tool in the manufacture of custom-made foot orthoses: a preliminary study

Background

Custom foot orthoses are currently recognized as the gold standard for treatment of foot and lower limb pathology. While foam and plaster casting methods are most widely used in clinical practice, technology has emerged, permitting the use of 3D scanning, computer aided design (CAD) and computer aided manufacturing (CAM) for fabrication of foot molds and custom foot orthotic components. Adoption of 3D printing, as a form of CAM, requires further investigation for use as a clinical tool.

This study provides a preliminary description of a new method to manufacture foot orthoses using a novel 3D scanner and printer and compare gait kinematic outputs from shod and traditional plaster casted orthotics.

Findings

One participant (male, 25 years) was included with no lower extremity injuries. Foot molds were created from both plaster casting and 3D scanning/printing methods. Custom foot orthoses were then fabricated from each mold. Lower body plug-in-gait with the Oxford Foot Model on the right foot was collected for both orthotic and control (shod) conditions. The medial longitudinal arch was measured using arch height index (AHI) where a decrease in AHI represented a drop in arch height. The lowest AHI was 21.2 mm in the running shoes, followed by 21.4 mm wearing the orthoses made using 3D scanning and printing, with the highest AHI of 22.0 mm while the participant wore the plaster casted orthoses.

Conclusion

This preliminary study demonstrated a small increase in AHI with the 3D printing orthotic compared to the shod condition. A larger sample size may demonstrate significant patterns for the tested conditions.

Gait assessment during the initial fitting of customized selective laser sintering ankle foot orthoses in subjects with drop foot

BACKGROUND

Recently, additive fabrication has been proposed as a feasible engineering method for manufacturing of customized ankle foot orthoses (AFOs). Consequently, studies on safety, comfort and effectiveness are now carried out to assess the performance of such devices.

OBJECTIVE

Evaluate the clinical performance of customized (selective laser sintering) SLS-AFOs on eight subjects with unilateral drop foot gait and compare to clinically accepted (polypropylene) PP-AFOs.

STUDY DESIGN

Active control trial.

METHODS

For each subject two customized AFOs were fabricated: one SLS-AFO manufactured following an additive fabrication framework and one thermoplastic PP-AFO manufactured according to the traditional handcraft method. Clinical performance of both AFOs was evaluated during gait analysis.

RESULTS

A significant beneficial effect of both custom-moulded PP-AFO and customized SLS-AFO in terms of spatial temporal gait parameters and ankle kinematic parameters compared to barefoot gait of adults with drop foot gait are observed. No statistically significant difference between the effect of PP-AFO and of SLS-AFO was found in terms of spatial temporal gait parameters and ankle kinematic parameters.

CONCLUSION

AFOs manufactured through the SLS technique show performances that are at least equivalent to the handcrafted PP-AFOs commonly prescribed in current clinical practice. Clinical relevance Manufacturing personalized AFOs with selective laser sintering (SLS) in an automated production process results in decreased production time and guarantees the consistency of shape and functional characteristics over different production time points compared to the traditional manufacturing process. Moreover, it reduces the dependency of the appliance on the experience and craftsmanship of the orthopaedic technician.

An exoskeleton using controlled energy storage and release to aid ankle propulsion

Symmetric ankle propulsion is the cornerstone of efficient human walking. The ankle plantar flexors provide the majority of the mechanical work for the step-to-step transition and much of this work is delivered via elastic recoil from the Achilles' tendon - making it highly efficient. Even though the plantar flexors play a central role in propulsion, body-weight support and swing initiation during walking, very few assistive devices have focused on aiding ankle plantarflexion. Our goal was to develop a portable ankle exoskeleton taking inspiration from the passive elastic mechanisms at play in the human triceps surae-Achilles' tendon complex during walking. The challenge was to use parallel springs to provide ankle joint mechanical assistance during stance phase but allow free ankle rotation during swing phase. To do this we developed a novel `smart-clutch' that can engage and disengage a parallel spring based only on ankle kinematic state. The system is purely passive - containing no motors, electronics or external power supply. This `energy-neutral' ankle exoskeleton could be used to restore symmetry and reduce metabolic energy expenditure of walking in populations with weak ankle plantar flexors (e.g. stroke, spinal cord injury, normal aging).