Effect of powered gait orthosis on walking in individuals with paraplegia

Effects of lower limb exoskeleton gait orthosis compared to mechanical gait orthosis on rehabilitation of patients with spinal cord injury: A systematic review and future perspectives

OBJECTIVE

We aimed to systematically evaluate the walking efficiency of lower limb exoskeleton gait orthosis and mechanical gait orthosis in patients with spinal cord injury.

DATA SOURCES

Databases searched included: Web of Science, MEDLINE, Cochrane Library and Google Scholar.

STUDY SELECTION

Articles published in English from 1970 to 2022 investigating the impact of lower limb exoskeleton gait orthosis versus mechanical gait orthosis on gait outcomes in patients with spinal cord injury were considered.

DATA EXTRACTION

Two researchers independently extracted data and filled out predesigned forms. Information including authors, year of study, methodological quality, participant characteristics, intervention and comparison details, outcomes and results. The primary outcomes were kinematic data; the secondary outcomes were clinical tests.

DATA SYNTHESIS

Data synthesis using meta-analysis was not possible due to the diversity of study designs, methodologies, and outcome measures.

RESULTS

A total of 11 trials and 14 types of orthotics were included. The information gathered generally supported the gait improving effects of lower limb exoskeleton gait orthosis and mechanical gait orthosis in both kinematic data and clinical tests among patients with spinal cord injury.

CONCLUSIONS

This systematic review compared walking efficiency of patients with spinal cord injury wearing powered exoskeleton gait orthosis and non-powered mechanical gait orthosis. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to verify the above conclusions. Future research should focus on improving trial quality and comprehensive parametric analysis of subjects with different physical conditions.

Advances in the clinical application of orthotic devices for stroke and spinal cord injury since 2013

Stroke and spinal cord injury are common neurological disorders that can cause various dysfunctions. Motor dysfunction is a common dysfunction that easily leads to complications such as joint stiffness and muscle contracture and markedly impairs the daily living activities and long-term prognosis of patients. Orthotic devices can prevent or compensate for motor dysfunctions. Using orthotic devices early can help prevent and correct deformities and treat muscle and joint problems. An orthotic device is also an effective rehabilitation tool for improving motor function and compensatory abilities. In this study, we reviewed the epidemiological characteristics of stroke and spinal cord injury, provided the therapeutic effect and recent advances in the application of conventional and new types of orthotic devices used in stroke and spinal cord injury in different joints of the upper and lower limbs, identified the shortcomings with these orthotics, and suggested directions for future research.

Lower limb sagittal kinematic and kinetic modeling of very slow walking for gait trajectory scaling

Lower extremity powered exoskeletons (LEPE) are an emerging technology that assists people with lower-limb paralysis. LEPE for people with complete spinal cord injury walk at very slow speeds, below 0.5m/s. For the able-bodied population, very slow walking uses different neuromuscular, locomotor, postural, and dynamic balance control. Speed dependent kinetic and kinematic regression equations in the literature could be used for very slow walking LEPE trajectory scaling; however, kinematic and kinetic information at walking speeds below 0.5 m/s is lacking. Scaling LEPE trajectories using current reference equations may be inaccurate because these equations were produced from faster than real-world LEPE walking speeds. An improved understanding of how able-bodied people biomechanically adapt to very slow walking will provide LEPE developers with more accurate models to predict and scale LEPE gait trajectories. Full body motion capture data were collected from 30 healthy adults while walking on an instrumented self-paced treadmill, within a CAREN-Extended virtual reality environment. Kinematic and kinetic data were collected for 0.2 m/s-0.8 m/s, and self-selected walking speed. Thirty-three common sagittal kinematic and kinetic gait parameters were identified from motion capture data and inverse dynamics. Gait parameter relationships to walking speed, cadence, and stride length were determined with linear and quadratic (second and third order) regression. For parameters with a non-linear relationship with speed, cadence, or stride-length, linear regressions were used to determine if a consistent inflection occurred for faster and slower walking speeds. Group mean equations were applied to each participant's data to determine the best performing equations for calculating important peak sagittal kinematic and kinetic gait parameters. Quadratic models based on walking speed had the strongest correlations with sagittal kinematic and kinetic gait parameters, with kinetic parameters having the better results. The lack of a consistent inflection point indicated that the kinematic and kinetic gait strategies did not change at very slow gait speeds. This research showed stronger associations with speed and gait parameters then previous studies, and provided more accurate regression equations for gait parameters at very slow walking speeds that can be used for LEPE joint trajectory development.

Influence of Reciprocating Link When Using an Isocentric Reciprocating Gait Orthosis (IRGO) on Walking in Patients with Spinal Cord Injury: A Pilot Study

Background: Studies collectively imply that the reciprocal link has no effect on walking when using reciprocating gait orthoses (RGOs). There may be differences between the 2 configurations of the RGO (eg, isocentric reciprocating gait orthosis [IRGO] and IRGO without reciprocating link), but the specific benefits and problems encountered in their use must be understood. Purpose: To highlight more evidence for the mechanical function of the reciprocal link in RGOs used for walking by individuals with spinal cord injury (SCI). Methods: Nine people with SCI participated in this study. Gait analysis was performed in 2 conditions (walking with IRGO and walking with IRGO without reciprocating link) in a random order. The Vicon digital capture system was used to obtain kinematic data. Results: There were significant differences between each orthotic configuration in terms of speed of walking (p = .029), step length (p = .048), hip joint range of motion (ROM) (p ≤ .001), and lateral and vertical compensatory motions (p ≤ .001). There was no significant difference between each orthotic configuration in cadence (p = .162). Conclusion: The reciprocating link in IRGO improved the walking parameters in SCI patients.

The influence of orthosis options on walking parameters in spinal cord-injured patients: a literature review

OBJECTIVE

Orthoses for various joints sections are considered to greatly influence the gait function and energy expenditure in spinal cord-injured (SCI) patients. The aim of this review was to determine the influence of orthoses characteristics and options on the improvement of walking in patients with SCI.

METHODS

A search was performed using the Population Intervention Comparison Outcome (PICO) method, based on selected keywords; studies were identified electronically in the Science Direct, Google Scholar, Scopus, Web of Knowledge and PubMed databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to report the results. Assessment of the quality of all articles was performed based on the Physiotherapy Evidence Database (PEDro scale).

RESULTS

Twelve studies evaluated the effects of different hip joint options on walking parameters and energy expenditure. Five studies investigated the role of knee joint options on gait parameters and compensatory trunk motion. Only five studies analyzed modified ankle joints on gait parameters in SCI patients. Nine studies analyzed gait parameters in SCI patients as powered orthoses and exoskeleton. These studies had a low level of evidence according to the PEDro score (2/10).

CONCLUSION

The various joint types of orthoses appear to be critical in the improvement of walking in patients with SCI. In particular, 'user friendly' orthoses that support the related structure such as the hip joint with a reciprocating mechanism, activated knee joint and movable ankle joint with dorsiflexion assist enable SCI patients to optimize their walking pattern when wearing an orthoses system.

The effect of ankle joint mobility when using an isocentric reciprocating gait orthosis (IRGO) on energy consumption in people with spinal cord injury: preliminary results

OBJECTIVES

The aim of this study was to evaluate the effect of walking with isocentric reciprocating gait orthoses (IRGOs) utilizing two designs of ankle foot orthoses (AFOs) on specific outcome measures in people with spinal cord injury (SCI).

METHODS

Four volunteer SCI subjects participated in this study, and were fitted with an IRGO equipped with either solid or dorsiflexion-assisted AFOs in a randomized order. Subjects walked at their self-selected speed along a flat walkway to enable a comparison of walking speed, endurance and the resulting physiological cost index (PCI) to be performed.

RESULTS

Increased walking speed, increased distance walked and less PCI were demonstrated in walking with the IRGO incorporating dorsiflexion-assisted AFOs as compared to walking with an IRGO plus solid AFO as a control condition.

CONCLUSION

This study demonstrated that people with SCI could walk at relatively higher speeds and with greater endurance and a reduced PCI when utilizing an IRGO with dorsiflexion-assisted AFO components compared to solid ones. It is therefore concluded that the IRGO incorporating dorsiflexion-assisted AFOs may be an effective alternative in helping to reduce the energy consumption experienced by people with SCI.

The influence of trunk extension in using advanced reciprocating gait orthosis on walking in spinal cord injury patients: A pilot study

BACKGROUND

Spinal cord injury patients walk with a flexed trunk when using reciprocating gait orthoses. Reduction of trunk flexion during ambulation may produce an improvement in gait parameters for reciprocating gait orthosis users.

OBJECTIVES

To investigate the effect on kinematics and temporal-spatial parameters when spinal cord injury patients ambulate with an advanced reciprocating gait orthosis while wearing a thoracolumbosacral orthosis to provide trunk extension.

STUDY DESIGN

Comparative study between before and after use o thoracolumbosacral orthosis with the advanced reciprocating gait orthoses.

METHODS

Four patients with spinal cord injury were fitted with an advanced reciprocating gait orthosis and also wore a thoracolumbosacral orthosis. Patients walked along a flat walkway either with or without the thoracolumbosacral orthosis at their self-selected walking speed. Temporal-spatial parameters and lower limb kinematics were analyzed.

RESULTS

Mean walking speed, step length, and cadence all improved when walking with the thoracolumbosacral orthosis donned compared to the trunk support offered by the advanced reciprocating gait orthosis. Hip and ankle joint ranges of motion were significantly increased when wearing the thoracolumbosacral orthosis during ambulation.

CONCLUSION

Using an advanced reciprocating gait orthosis when wearing a thoracolumbosacral orthosis can improve walking speed and the step length of walking as compared with walking with an advanced reciprocating gait orthosis, probably due to the extended position of the trunk.

CLINICAL RELEVANCE

Donning the thoracolumbosacral orthosis produced a relatively extended trunk position in the advanced reciprocating gait orthosis for all the patients included in the study, which resulted in improved gait parameters.

The influence of orthotic gait training with an isocentric reciprocating gait orthosis on the walking ability of paraplegic patients: a pilot study

OBJECTIVES

The aim of this study was to evaluate the influence of walking with an isocentric reciprocating gait orthosis (IRGO) by spinal cord injury (SCI) patients on walking speed, distance walked and energy consumption whilst participating in a 12-week gait re-training program.

METHODS

Six people with motor complete SCI (mean age 29 years, weight 63 kg and height 160 cm with injury levels ranging from T8 to T12) participated in this study. Gait evaluation was performed at baseline and after 4, 8 and 12 weeks. Walking speed and heart rate were measured to calculate the resulting physiological cost index (PCI).

RESULTS

Reductions in energy consumption were observed after 4, 8 and 12 weeks compared with baseline but were not significant. However, walking distance increased significantly (P=0.010, P=0.003 and P=0.005, respectively) and also did so during the 8-12-week period (P=0.013). Walking speed also improved, but not significantly.

CONCLUSION

Intensive gait training with the IRGO improved walking speed and the distance walked by paraplegics, as well as reducing the PCI of walking, as compared with baseline during the whole 12-week period. This indicates that further improvements in these parameters may be expected when utilizing gait training longer than 8 weeks.

The efficacy of powered orthoses on walking in persons with paraplegia

BACKGROUND

Powered orthoses are a new generation of assistive devices for people with spinal cord injury, which are designed to induce motion to paralyzed lower limb joints using external power via electric motors or pneumatic or hydraulic actuators.

OBJECTIVE

Powered gait orthoses provide activated movement of lower limb joints to limit the forces applied through the upper limb joints and trunk muscles during ambulation due to the need to use an external walking aid, while simultaneously improving the kinetics and kinematics of walking in subjects with spinal cord injury. This article reviews their walking efficacy when used by people with paraplegia.

STUDY DESIGN

Literature review.

METHOD

A literature search was performed in ISI Web of Knowledge, PubMed, Google Scholar, ScienceDirect, and Scopus databases.

RESULTS

Efficacy was demonstrated in producing activated motion of lower limb joints. Powered gait orthoses have a beneficial effect on the kinetics, kinematics, and temporal-spatial parameters of gait, but their effect on muscle activity in individuals with spinal cord injury is still unclear.

CONCLUSIONS

Further research is needed regarding the design and construction of powered gait orthoses using significant power application to the ankle joints and their effect on lower limb muscle activity and gait patterns in spinal cord injury subjects.

CLINICAL RELEVANCE

Powered orthoses is a new generation of orthotic intervention that could potentially be significant in assisting in improving the walking parameters and energy consumption of spinal cord injury subjects.

The efficiency of orthotic interventions on energy consumption in paraplegic patients: a literature review

Study design:This is a systematic literature review.Objectives:Different types of orthoses have been developed to enable and facilitate ambulation in individuals with paraplegia. However, their effect on energy consumption while ambulating is not clear. The objective of this review was to compare the energy expenditure required to walk with these devices.Methods:Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, and based on selected keywords and their composition according to the Population Intervention Comparison Outcome (PICO) method, a search was performed in Science Direct, Google Scholar, Scopus, Web of Knowledge and PubMed databases. The searches were restricted to papers published in the English language and were conducted during February 2014; the last access to the database was on 25 February 2014. A total of 24 articles were chosen for final evaluation.Results:Hybrid orthoses reduce energy consumption compared with mechanical orthoses when used for walking by paraplegic patients. The isocentric reciprocating gait orthosis has been shown to be more effective than other reciprocating orthoses in reducing energy consumption. Energy consumption when walking with powered orthoses (PO) and hybrid orthoses was also reduced compared with when walking with conventional orthoses.Conclusions:The hybrid orthoses and PO could be effective alternatives in rehabilitation for spinal cord injury patients to help improve the energy consumption.Spinal Cord advance online publication, 20 January 2015; doi:10.1038/sc.2014.227.