Advanced Reciprocating Gait Orthosis Research Articles

The effect of trunk extension on physiological cost index in spinal cord injury patients when using the advanced reciprocating gait orthosis: A pilot study.

People with spinal cord injury walk with a flexed trunk when using reciprocating gait orthoses for walking. Reduction in trunk flexion during ambulation has been shown to improve gait parameters for reciprocating gait orthosis users. The aim of this study was to investigate the effect on energy expenditure when spinal cord injury patients ambulate with an advanced reciprocating gait orthosis while wearing a thoracolumbosacral orthosis to provide trunk extension. Quasi experimental study. Four patients with spinal cord injury were fitted with an advanced reciprocating gait orthosis after completing a specific gait training program. Patients walked along a flat walkway using the advanced reciprocating gait orthosis as a control condition and also while additionally wearing a thoracolumbosacral orthosis at their self-selected walking speed. A stopwatch and a polar heart rate monitor were used to measure walking speed and heart rate. Walking speed, the distance walked, and the physiological cost index all improved when walking with the advanced reciprocating gait orthosis/thoracolumbosacral orthosis test condition compared to walking with no thoracolumbosacral orthosis in situ. Spinal cord injury patients can improve their walking speed, walking distance, and physiological cost index when wearing a thoracolumbosacral orthosis in conjunction with an advanced reciprocating gait orthosis, which may be attributed to the trunk extension provided by the thoracolumbosacral orthosis. It is concluded that wearing thoracolumbosacral orthosis in association with an advanced reciprocating gait orthosis could be an effective alternative in rehabilitation for thoracic level of paraplegic patients to promote their health and well-being.

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

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. 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. Comparative study between before and after use o thoracolumbosacral orthosis with the advanced reciprocating gait orthoses. 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. 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. 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. 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 a rocker sole adaptation on gait parameters in spinal cord injury patients ambulating with the advanced reciprocating gait orthosis – a pilot study

Objective: When walking with an advanced reciprocating gait orthosis (ARGO), ankle and knee joint motion is restricted which causes an un-cosmetic gait compared to normal walking. The purpose of this study was to develop and evaluate a rocker modification for use with the ARGO in order to improve hip joint kinematics, walking speed, step length and cadence. Method: Spinal cord injury patients (n = 4) with thoracic-level injury participated in this study, and walked with a standard ARGO and one which was also adapted with a rocker sole in a randomized order. Results: Mean walking speed and step length were both significantly increased by volunteer SCI subjects when ambulating using the ARGO adapted with a rocker sole compared to the standard ARGO. Cadence was not significantly affected, but swing time was significantly reduced and mean hip flexion and extension were both significantly increased when walking with the adapted ARGO. Conclusion: The rocker sole modification produced an increase in walking speed and step length, and improved sagittal plane hip joint kinematics when ambulating using an ARGO. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard unmodified version.Implications for RehabilitationThe ARGO adapted with a rocker sole could be used by spinal cord injury patients.A major advantage of the walking with the ARGO adapted with a rocker sole was increased of walking speed and step length, and improvement of the sagittal plane hip joint kinematics.The findings of this study would appear to provide useful data for rehabilitation teams who utilize orthoses to walk and rehabilitate SCI subjects. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard un-modified version.

The influence of ankle joint mobility when using an orthosis on stability in patients with spinal cord injury: a pilot study

Perceived risk of falling is an important factor for people with spinal cord injury (SCI). This study investigated the influence of ankle joint motion on postural stability and walking in people with SCI when using an orthosis. Volunteer subjects with SCI (n=5) participated in this study. Each subject was fitted with an advanced reciprocating gait orthosis (ARGO) equipped with either solid or dorsiflexion-assist type ankle-foot orthosis (AFOs) and walked at their self-selected speed along a flat walkway to enable the comparison of walking speed, cadence and endurance. A force plate system and a modified Falls Efficacy Scale (MFES) were utilized to measure postural sway and the perceived fear of falling, respectively. There were significant differences in the mean MFES scores between two types of orthosis (P=0.023). When using two crutches, there was no significant difference in static standing postural sway in the medio-lateral (M/L) direction (P=0.799), but significant difference in the antero-posterior (A/P) direction (P=0.014). However, during single crutch support, there was a significant difference in both M/L (P=0.019) and A/P (P=0.022) directions. Walking speed (7%) and endurance (5%) significantly increased when using the ARGO with dorsi flexion assisted AFOs. There was no significant deference between two types of orthoses in cadence (P=0.54). Using an ARGO with dorsiflexion-assisted AFOs increased the fear of falling, but improved static postural stability and increased walking speed and endurance, and should therefore be considered as an effective orthosis during the rehabilitation of people with SCI.

Gait evaluation of the advanced reciprocating gait orthosis with solid versus dorsi flexion assist ankle foot orthoses in paraplegic patients

Mechanical orthoses are used for standing and walking after neurological injury. Most orthoses such as the advanced reciprocating gait orthosis typically use solid ankle-foot orthoses. The goal of this study was to test the effects of ankle dorsiflexion assistance in patients with spinal cord injury when ambulating with an advanced reciprocating gait orthosis compared to walking with fixed ankles. Quasi-experimental. Four patients with spinal cord injury were fitted with an advanced reciprocating gait orthosis equipped with solid and dorsiflexion assist-type ankle-foot orthoses and walked at their self-selected speed. Joint angles and spatial-temporal parameters were measured and analyzed. The mean walking speed and stride length were both significantly increased along with cadence by the volunteer subjects when ambulating using the advanced reciprocating gait orthosis fitted with dorsiflexion assist ankle-foot orthoses compared to the advanced reciprocating gait orthosis with solid ankle-foot orthoses. The mean ankle joint ranges of motion were significantly increased when walking with the advanced reciprocating gait orthosis with dorsiflexion assist ankle-foot orthoses compared to when using the advanced reciprocating gait orthosis with the solid ankle-foot orthoses. Knee joint ranges of motion were reduced, and hip joint ranges of motion were increased but not significantly. The advanced reciprocating gait orthosis fitted with the dorsiflexion assist ankle-foot orthoses had the effect of improving gait parameters when compared to the advanced reciprocating gait orthosis with solid ankle-foot orthoses. Clinical relevance The advanced reciprocating gait orthosis with dorsiflexion assist ankle-foot orthoses has the potential to improve hip and ankle joint kinematics and the temporal-spatial parameters of gait in spinal cord injury patients' walking.

Studying the effect of kinematical pattern on the mechanical performance of paraplegic gait with reciprocating orthosis

Paraplegic users of mechanical walking orthoses, e.g. advanced reciprocating gait orthosis (ARGO), often face high energy expenditure and extreme upper body loading during locomotion. We studied the effect of kinematical pattern on the mechanical performance of paraplegic locomotion, in search for an improved gait pattern that leads to lower muscular efforts. A three-dimensional, four segment, six-degrees-of-freedom skeletal model of the advanced reciprocating gait orthosis-assisted paraplegic locomotion was developed based on the data acquired from an experimental study on a single subject. The effect of muscles was represented by ideal joint torque generators. A response surface analysis was performed on the model to determine the impact of the kinematical parameters on the resulting muscular efforts, characterized by net joint torques. Results indicated that a lateral bending manoeuvre at the trunk would facilitate the foot clearance by reducing the torque requirement of the whole body lateral tilting. For swing leg advancement, the trunk posterior bending manoeuvre was found to be more effective and efficient than the whole body axial rotation, owing to the coupled reciprocal action of the advanced reciprocating gait orthosis. It was hypothesized that a modified gait pattern, with larger trunk movements and no axial rotation, could improve the energy expenditure and upper body loading during advanced reciprocating gait orthosis-assisted locomotion. More detailed modelling and experimental studies are needed to verify this hypothesis and evaluate its potential effects on the soft tissue strains.

Effect of Dynamic Knee Motion on Paralyzed Lower Limb Muscle Activityduring Orthotic Gait: A Test for the Effectiveness of the Motor-Assisted Knee Motion Device

Orthotic gait in paraplegic persons is a “stiff-leg” gait, which is a gait with the knee locked in full extension position. We developed a motor-assisted knee motion device with the use of a pair of linear electric actuator attached to the knee joint of a conventional reciprocal gait orthosis (Advanced Reciprocating Gait Orthosis: ARGO). The purpose of this study was to examine the effect of dynamic knee motion on lower limb muscle electromyographic (EMG) activity during orthotic gait. Six motor complete spinal cord injured persons participated, and the subjects were asked to walk on a treadmill with two types of orthoses; Knee-ARGO and Normal-ARGO. The results demonstrated that magnitude of EMG activity in the gastrocnemius and the rectus femoris muscles was significantly increased by an accomplished dynamic knee motion. These changes might be attributed to the occurrence of an additional afferent neural input with the knee motion. The present results suggest that the assisted knee motion by generating powered device have a potential to activate the neuromuscular function in the paralyzed lower limb.

Effect of intrathecal baclofen, botulinum toxin type A and a rehabilitation programme on locomotor function after spinal cord injury: A case report

A few studies have reported the use of botulinum toxin injections after spinal cord injury, as this is the gold standard to treat focal spasticity. We report such a case here. A 38-year-old woman who had become paraplegic and care-dependent secondary to cervico-thoracic intramedullary ependymoma, presented 8 months later with painful lower limb spasticity, which was being treated with oral anti-spastic and benzodiazepine drugs with no therapeutic effect. We treated the patient with intrathecal baclofen to reduce her spasticity and in order to avoid the major side-effects of high dosages of oral baclofen. After motor rehabilitation programmes, which included functional electrical stimulation, the patient was able to wear an advanced reciprocating gait orthosis. However, she experienced painful muscle spasms in her toes of the feet that limited her gait. Therefore, she was also treated with bilateral injections of botulinum toxin type A into the flexor digitorum brevis muscles. The patient reported relief of spasms and pain, enabling her to wear an advanced reciprocating gait orthosis and facilitating rehabilitation programmes. The use of botulinum toxin type A may be an important adjunctive therapy to increase the therapeutic effect of baclofen on spasticity in small muscles, resulting in a more focal effect, and improving the use of orthoses and the effectiveness of rehabilitation programmes in patients after spinal cord injury.

Influence of an advanced reciprocating gait orthosis on walking function in complete spinal cord injury patients

Objective To explore the value of an advanced reciprocating gait orthosis (ARGO) combined with comprehensive rehabilitation treatment in rehabliltating complete spinal cord injury (SCI) patients. Methods Twelve patients with complete SCI at the T4~L2 level were fitted with an ARGO. Before and after fitting the ARGO,comprehensive rehabilitative excecises were conducted. After training, ambulation was evaluated, and competence in the activities of daily living was evaluated using the Barthel index and Functional Independence Measure. Results The patients' ambulation improved markedly after fitting the ARGO and training. Barthel index and FIM scres improved significantly. All 12 patients achieved therapeutic or functional ambulation. Conclusion With the aid of an ARGO, patients suffering from complete SCI below the T4 level can achieve functional walking and improve their quality of life. Key words: Spinal cord injury; Advanced reciprocating gait orthosis; Walking function

A two-degree-of-freedom motor-powered gait orthosis for spinal cord injury patients

A number of orthoses have been developed to restore stance and walking in paraplegic subjects. Compliance, however, has been limited, mainly owing to walking effort. Use of the forces produced by actuators is an effective way to solve the problem of the considerable effort required for orthotic gait, namely high muscular effort and high energy expenditure. The purpose of the present study was to investigate the effects of assistance by external actuators on the orthotic gait of spinal cord injury (SCI) patients. Two kinds of linear actuator were developed by using direct current (d.c.) motors for assisting the knee and hip joint of a gait orthosis. They were mounted on the knee and hip joint of a commercial advanced reciprocating gait orthosis (ARGO), and a new two-degree-of-freedom externally powered gait orthosis was thus developed. The orthosis was assessed through inter-subject experiments on five male adult complete SCI patients. Owing to the short training period available for the assisted gait, simultaneous operation of both joint actuators was not conducted: either the knee actuation or the hip actuation was executed only. Thus, the knee actuator and the hip actuator were assessed with a T12 subject and with subjects for T5, T8, T11, and T12 respectively. The motions of the gaits, assisted by the linear actuators, were measured by a Vicon 370 system, and the general gait parameters and compensatory motions were evaluated. Results demonstrated that (a) all subjects could walk without falling, assisted either by the knee or the hip actuator; (b) both the knee and hip joint actuator increased the gait speed and the step length; (c) the knee flexion produced by the orthosis improved the dynamic cosmesis of walking; and (d) lateral compensatory motions as well as vertical ones tended to decrease when the hip joint was assisted, which could contribute to a reduction in walking effort.

Energy consumption of locomotion with orthosis versus Parastep-assisted gait: a single case study

Single case study. To evaluate the energy expenditure during ambulation with the Advanced Reciprocating Gait Orthosis (ARGO), with and without functional electrical stimulation (FES), and with the Parastep system in a single subject, in order to avoid the effect of inter-subject variability. The Centre of Sport Medicine and Bioengineering Centre 'Don C Gnocchi' Foundation ONLUS IRCCS, Milano, Italy. A single patient (lesion level T5-T6) was trained specifically for each walking system and was evaluated after each training period. The effects of FES on muscle conditioning, spasticity and bone density were also evaluated. The HR/VO2 relationship and the energy cost of locomotion were measured during wheelchair (WHCH) use, during locomotion with ARGO (with and without FES) and Parastep system at different speeds. The following was observed at the end of the whole training: (a) circumferences of both lower limbs and quadriceps forces were increased, whereas fatigue index was slightly decreased, spasticity and bone density were unchanged; (b) compared to WHCH locomotion, the slope of HR/VO2 curves with ARGO was higher (slope difference=51.1 b 1O2(-1)), with ARGO+FES was similar (slope difference=-5.3 b 1O2(-1)) and with Parastep was smaller (slope difference=-55.6 b 1O2(-1)); (c) HR increased linearly with all locomotion systems, but did not rise above 125 bpm with Parastep; (d) the cost of locomotion was higher with Parastep than with ARGO (with and without FES), tested at each velocity; (e) Parastep appears to be easier to use for the subject. (a) FES can improve ambulation with orthosis, but the cost of locomotion remains very high; (b) the Parastep assisted gait elicits a higher energy expenditure than other orthoses, probably due to the lower speed of locomotion and to the high isometric effort of the stimulated muscles. This work has been partially supported by the Italian Minister of Public Health (Ricerca Finalizzata IRCCS no ICS030.7/RF97.25).

Validity and reproducibility of crutch force and heart rate measurements to assess energy expenditure of paraplegic gait

Objective: To determine the validity and reproducibility of heart rate (HR) and crutch force measurements to estimate energy expenditure during paraplegic walking. Usefulness of these outcome measures in comparative trials was assessed in terms of responsiveness. Design: Cross-sectional validity was determined using one single (first) measurement. Longitudinal validity as well as reproducibility were calculated using repeated measurements. Setting: Oxygen uptake and HR during steady state as well as axial crutch load were measured at subjects' self-selected walking speeds. Patients: Ten subjects with thoracic-level spinal cord injury were included in the study. All subjects had considerable experience with ambulation in the advanced reciprocating gait orthosis (ARGO). Main Outcome Measures: Oxygen uptake (V̇O 2, mL/min) and oxygen cost (Eo 2, mL/m) were used as criterion standards. Crutch peak force (CPF), crutch force time integral (CFTI), HR, and physiological cost index (PCI) were used to estimate energy expenditure. Results: The PCI was found to be sensitive to detect differences between sessions in criterion standard ( r = .86). Smallest detectable difference (ie, point where difference exceeds measurement error) ranged from approximately 15% for CPF to 33.7% and 41.8% for Eo 2 and PCI, respectively. Conclusions: Although PCI is expected to be a valid measure for within-patient differences in V̇O 2, responsiveness was lower compared to Eo 2 and CPR. The limited number of patients who can be included in studies on paraplegic locomotion requires reproducible outcome measures. Therefore, CPF and Eo 2 are advocated in favor of PCI.

Speed dependence of crutch force and oxygen uptake: Implications for design of comparative trials on orthoses for people with paraplegia

Objective: To determine speed dependence of crutch force and oxygen uptake, and to discuss the implications of differences in self-selected walking speed between orthoses in a comparative trial. Design: Cross-sectional comparison. Setting: Treadmill experiments and gait laboratory experiments were performed at five and three different imposed walking speeds, respectively. Patients: Five paraplegic subjects with lesions between T9 and T12 were included. All subjects had experience with ambulation using the advanced reciprocating gait orthosis (ARGO) as well as walking on a treadmill. Main Outcome Measures: Crutch force time integral (CFTI), crutch peak force on stance and swing side (CPF stance and CPF swing), oxygen uptake ( V o 2 ), oxygen cost ( E o 2 ). Results: V o 2 , E o 2 , and CFTI were strongly dependent on walking speed. CPF stance and CPF swing were less dependent. However, depending on the clinically relevant difference that should be detected in a comparative trial, the peak forces can still be confounded by walking speed. Conclusion: CFTI, CPF swing, V o 2 , and E o 2 should be adjusted for walking speed if differences in walking speed between orthoses are found, but this correction is relevant only if there is no effect modification. Such modification (different slopes between orthoses) cannot be excluded for the studied outcome measures. In addition, because determination of effect modification is difficult in small studies, standardization of walking speed, by means of a three-point design, is recommended.