Ankle Push-off Research Articles

Near-Normal Gait Pattern With Peroneal Electrical Stimulation as a Neuroprosthesis in the Chronic Phase of Stroke: A Case Report

van Swigchem R, Weerdesteyn V, van Duijnhoven HJ, den Boer J, Beems T, Geurts AC. Near-normal gait pattern with peroneal electrical stimulation as a neuroprosthesis in the chronic phase of stroke: a case report. In recent years, the use of functional electrical stimulation (FES) of the peroneal nerve has increased as an alternative for an ankle-foot orthosis (AFO) to treat stroke-related drop foot. We present a chronic stroke patient demonstrating an almost normal gait pattern with peroneal FES as a neuroprosthesis. A 60-year-old survivor of a right hemisphere infarction 21 months ago, who regularly used a polypropylene AFO, was provided with a surface-based peroneal FES device for severe drop foot. In a second instance, he received an implanted FES system because of skin problems with the surface stimulator. With both FES devices, the patient achieved an adequate foot elevation. Moreover, his hip and knee flexion angles during walking increased to normal values and his ankle push-off power increased. His gait pattern became almost symmetrical and less variable than with the AFO. Furthermore, his ability to avoid a sudden obstacle improved to normal values with FES. Our patient showed benefits from peroneal FES beyond what can be attributed to improved foot lift alone. With regard to the potential working mechanisms underlying this response to FES, biomechanical benefits related to improved ankle push-off are suggested as the main mechanism.

Recycling Energy to Restore Impaired Ankle Function during Human Walking

BackgroundHumans normally dissipate significant energy during walking, largely at the transitions between steps. The ankle then acts to restore energy during push-off, which may be the reason that ankle impairment nearly always leads to poorer walking economy. The replacement of lost energy is necessary for steady gait, in which mechanical energy is constant on average, external dissipation is negligible, and no net work is performed over a stride. However, dissipation and replacement by muscles might not be necessary if energy were instead captured and reused by an assistive device.Methodology/Principal FindingsWe developed a microprocessor-controlled artificial foot that captures some of the energy that is normally dissipated by the leg and “recycles” it as positive ankle work. In tests on subjects walking with an artificially-impaired ankle, a conventional prosthesis reduced ankle push-off work and increased net metabolic energy expenditure by 23% compared to normal walking. Energy recycling restored ankle push-off to normal and reduced the net metabolic energy penalty to 14%.Conclusions/SignificanceThese results suggest that reduced ankle push-off contributes to the increased metabolic energy expenditure accompanying ankle impairments, and demonstrate that energy recycling can be used to reduce such cost.

Experimental study on the role of the ankle push off in the walk-to-run transition by means of a powered ankle-foot-exoskeleton

The goal of this study was to analyse the role of the plantarflexor muscles in the walk-to-run transition (WRT) by means of a powered ankle-foot-exoskeleton. 11 female subjects performed several WRT's on an accelerating treadmill while their plantarflexors were assisted or resisted during push off. The WRT speed was lower in the resist condition than in the control condition which reinforces hypotheses from previous simulations, descriptive and experimental studies. There was no increase in WRT speed in the assist condition which is in contrast to another study where the plantarflexor push off was assisted indirectly by a horizontal traction at waist level. The lack of effect from the assist condition in the present study is possibly due to the narrowly focused nature of the experimental manipulation.

Controlling the Walking Speed in Limit Cycle Walking

“Limit Cycle Walking” is a relatively new paradigm for the design and control of two-legged walking robots. It states that achieving stable periodic gait is possible without locally stabilizing the walking trajectory at every instant in time, as is traditionally done in most walking robots. Well-known examples of Limit Cycle Walkers are the Passive Dynamic Walkers, but recently there are also many actuated Limit Cycle Walkers. Limit Cycle Walkers generally use less energy than other existing bipeds, but thus far they have not been as versatile. This paper focuses on one aspect of versatility: walking speed. We study how walking speed can be varied, which way is energetically beneficial and how walking speed affects a walker's ability to handle disturbances (that is, disturbance rejection). The study is performed using one prototype and one simulation model. The speed of these two walkers is adapted by changing three parameters: the amount of ankle push-off, upper body pitch and step length. The study has resulted in four conclusions. (1) Steady-state speeds between 0.24 and 0.68 m s -1 (for a 0.6 m leg length) were obtained, with loss of stability determining the lower limit and actuation limits determining the upper limit. This result shows the applicability of Limit Cycle Walking for versatile walking machines. (2) For any speed, powering the gait by leaning the body forward costs less energy than using ankle push-off. (3) In contrast to the apparent tradeoff between speed and stability in traditional walking robots, in Limit Cycle Walking we find that increasing the walking speed, independent of how this is done, automatically results in an increasing disturbance rejection. (4) A combination of feedforward actuation adjustment and step-to-step feedback from walking speed shows that it is possible to change walking speed in only a few steps and maintain a desired speed when performing tasks such as carrying loads and walking on slopes. In particular, this fourth conclusion underlines the applicability of the concept of Limit Cycle Walking for versatile two-legged walking machines.

SHEAR LOAD SHARING IN THE HUMAN LUMBAR SPINE

In a simple bipedal walking model, an impulsive push along the trailing limb (similar to ankle plantar flexion) or a torque at the hip can power level walking. This suggests a tradeoff between ankle and hip muscle requirements during human gait. People with anterior hip pain may benefit from walking with increased ankle pushoff if it reduces hip muscle forces. The purpose of our study was to determine if simple instructions to alter ankle pushoff can modify gait dynamics and if resulting changes in ankle pushoff have an effect on hip muscle requirements during gait. We hypothesized that changes in ankle kinetics would be inversely related to hip muscle kinetics. Ten healthy subjects walked on a custom split-belt force-measuring treadmill at 1.25 m/s. We recorded ground reaction forces and lower extremity kinematic data to calculate joint angles and internal muscle moments, powers and angular impulses. Subjects walked under three conditions: natural pushoff, decreased pushoff and increased pushoff. For the decreased pushoff condition, subjects were instructed to push less with their feet as they walked. Conversely, for the increased pushoff condition, subjects were instructed to push more with their feet. As predicted, walking with increased ankle pushoff resulted in lower peak hip flexion moment, power and angular impulse as well as lower peak hip extension moment and angular impulse (p<0.05). Our results emphasize the interchange between hip and ankle kinetics in human walking and suggest that increased ankle pushoff during gait may help to compensate for hip muscle weakness or injury and reduce hip joint forces.

Walking with increased ankle pushoff decreases hip muscle moments

In a simple bipedal walking model, an impulsive push along the trailing limb (similar to ankle plantar flexion) or a torque at the hip can power level walking. This suggests a tradeoff between ankle and hip muscle requirements during human gait. People with anterior hip pain may benefit from walking with increased ankle pushoff if it reduces hip muscle forces. The purpose of our study was to determine if simple instructions to alter ankle pushoff can modify gait dynamics and if resulting changes in ankle pushoff have an effect on hip muscle requirements during gait. We hypothesized that changes in ankle kinetics would be inversely related to hip muscle kinetics. Ten healthy subjects walked on a custom split-belt force-measuring treadmill at 1.25 m/s. We recorded ground reaction forces and lower extremity kinematic data to calculate joint angles and internal muscle moments, powers and angular impulses. Subjects walked under three conditions: natural pushoff, decreased pushoff and increased pushoff. For the decreased pushoff condition, subjects were instructed to push less with their feet as they walked. Conversely, for the increased pushoff condition, subjects were instructed to push more with their feet. As predicted, walking with increased ankle pushoff resulted in lower peak hip flexion moment, power and angular impulse as well as lower peak hip extension moment and angular impulse ( p<0.05). Our results emphasize the interchange between hip and ankle kinetics in human walking and suggest that increased ankle pushoff during gait may help to compensate for hip muscle weakness or injury and reduce hip joint forces.

Ankle Actuation for Limit Cycle Walkers

Limit Cycle Walkers are bipeds that exhibit a stable cyclic gait without requiring local controllability at all times during gait. Well-known example are McGeer's “Passive Dynamic Walkers”, but the concept expands to actuated bipeds as involved in this study. Current state-of-the-art Limit Cycle Walkers excel in being very energy efficient, but their ability to handle disturbances (i.e. disturbance rejection) is still limited. A way to improve this ability while maintaining low energy consumption is the use of ankle actuation, which has so far seen few applications in this type of walker. In this paper we study the effect of (1) applying (passive) stiffness in the ankle joint, (2) applying control in the stance ankle based only on local sensor information and (3) modulating ankle push-off. For all three strategies the paper shows how they influence energy use and disturbance rejection of a simple point mass walking model, a more realistic model and a physical prototype. We find that applying a passive ankle spring that results in premature heel rise is energetically optimal and gives an actuation pattern that largely resembles that of humans. Local stance ankle control and ankle push-off modulation can improve the disturbance rejection of a Limit Cycle Walker by at least 60%, without increasing its energy use. These findings are substantiated by showing that our prototype is able to handle large disturbances such as a step-down of 5% of its leg length, while walking efficiently at a mechanical cost of transport of 0.09.

The effects of powered ankle-foot orthoses on joint kinematics and muscle activation during walking in individuals with incomplete spinal cord injury

BackgroundPowered lower limb orthoses could reduce therapist labor during gait rehabilitation after neurological injury. However, it is not clear how patients respond to powered assistance during stepping. Patients might allow the orthoses to drive the movement pattern and reduce their muscle activation. The goal of this study was to test the effects of robotic assistance in subjects with incomplete spinal cord injury using pneumatically powered ankle-foot orthoses.MethodsFive individuals with chronic incomplete spinal cord injury (ASIA C-D) participated in the study. Each subject was fitted with bilateral ankle-foot orthoses equipped with artificial pneumatic muscles to power ankle plantar flexion. Subjects walked on a treadmill with partial bodyweight support at four speeds (0.36, 0.54, 0.72 and 0.89 m/s) under three conditions: without wearing orthoses, wearing orthoses unpowered (passively), and wearing orthoses activated under pushbutton control by a physical therapist. Subjects also attempted a fourth condition wearing orthoses activated under pushbutton control by them. We measured joint angles, electromyography, and orthoses torque assistance.ResultsA therapist quickly learned to activate the artificial pneumatic muscles using the pushbuttons with the appropriate amplitude and timing. The powered orthoses provided ~50% of peak ankle torque. Ankle angle at stance push-off increased when subjects walked with powered orthoses versus when they walked with passive-orthoses (ANOVA, p < 0.05). Ankle muscle activation amplitudes were similar for powered and passive-orthoses conditions except for the soleus (~13% lower for powered condition; p < 0.05).Two of the five subjects were able to control the orthoses themselves using the pushbuttons. The other three subjects found it too difficult to coordinate pushbutton timing. Orthoses assistance and maximum ankle angle at push-off were smaller when the subject controlled the orthoses compared to when the therapist-controlled the orthoses (p < 0.05). Muscle activation amplitudes were similar between the two powered conditions except for tibialis anterior (~31% lower for therapist-controlled; p < 0.05).ConclusionMechanical assistance from powered ankle-foot orthoses improved ankle push-off kinematics without substantially reducing muscle activation during walking in subjects with incomplete spinal cord injury. These results suggest that robotic plantar flexion assistance could be used during gait rehabilitation without promoting patient passivity.

Quantitative Gait Analysis in Parkinson’s Disease: Comparison With a Healthy Control Group

Sofuwa O, Nieuwboer A, Desloovere K, Willems AM, Chavret F, Jonkers I. Quantitative gait analysis in Parkinson’s disease: comparison with a healthy control group. Objective To compare gait parameters in Parkinson’s disease (PD) during the on-phase of medication cycle with those of healthy elderly control subjects. Design A group-comparison study. Setting Gait analysis laboratory of a university hospital. Participants Fifteen patients with PD and 9 healthy elderly controls. Interventions Not applicable. Main outcome measures Spatiotemporal, kinematic, and kinetic gait parameters. Results The PD spatiotemporal results showed a significant reduction in step length and walking velocity compared with controls. In the kinematics, the major feature of the PD group was a markedly reduced ankle plantarflexion excursion (at 50%–60% of the gait cycle). Most important, the kinetics showed reduced ankle push-off power and hip pull-off power. Unlike the control subjects, the patients with PD did not show any correlation between ankle generation (push-off) power and stride length ( r=.19) or with gait speed ( r=.29). Correction for walking velocity did not result in significant changes in the kinetics between the groups. Conclusions Reduced ankle (push-off) power generation and reduced hip flexion (pull-off) power persisted in PD gait despite being tested in the on-phase of the medication cycle. Lack of a correlation between ankle and hip power generation and walking velocity suggests that peripheral and central factors contribute to lack of forward progression. Patients with PD may benefit from intervention strategies that correct the kinematic and the kinetic gait components.

Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke

<h2>Abstract</h2> Lamontagne A, Malouin F, Richards CL. Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke. Arch Phys Med Rehabil 2000;81:351-8. <b>Objective:</b> To measure the contribution of passive stiffness to the ankle plantarflexor moment during gait in subjects with hemiparesis early after stroke. The relationship of passive stiffness with gait speed was also examined. <b>Design:</b> Cross-sectional, descriptive. <b>Patients and Other Participants:</b> A sample of convenience of 14 patients (54.7 ± 10.9yrs) with a hemiparesis for less than 5 months and 11 healthy controls (50.6 ± 11.6yrs). <b>Main Outcome Measures:</b> The contribution of passive stiffness to the plantarflexor moment during gait was obtained using moment-angle slope (stiffness) values. Total plantarflexor stiffness was measured during gait, and passive stiffness was measured during passive dorsiflexion imposed by an isokinetic dynamometer at velocities and ranges of movement matched with values recorded during the plantarflexor lengthening period of the stance phase. The contribution of passive stiffness was obtained by dividing the passive stiffness (dynamometer) by the total plantarflexor stiffness (gait). <b>Results:</b> On the paretic side, passive stiffness contributed more (16.8%; range 2.9% to 49.6%) to total plantarflexor stiffness during gait compared (<i>p</i> <.01) with both the nonparetic side (7.3%) and control values (5.9%). This increased contribution on the paretic side resulted from a large muscle-tendon passive stiffness, a decreased active muscle contribution, or both. Although in some patients the increased passive component led to the development of a total plantarflexor stiffness that was within normal values, it did not in others either because the active component was very small or because limited dorsiflexion during the stance phase prevented the passive component tension to develop. The contribution of passive stiffness was not significantly (<i>p</i> >.05) related to gait speed in both the patients and the controls. <b>Conclusions:</b> The increased contribution of passive stiffness to total plantarflexor moment during gait likely acts as an adaptation for a defective muscle active component, helping ankle push-off at the end of the stance phase. Although this mechanism is effective in most of the patients, it cannot come into action if the dorsiflexion movement during the stance phase is prevented, for instance, by enhanced stretch reflexes. <i>© 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation</i>

Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke

Objective: To measure the contribution of passive stiffness to the ankle plantarflexor moment during gait in subjects with hemiparesis early after stroke. The relationship of passive stiffness with gait speed was also examined.Design: Cross-sectional, descriptive.Patients and Other Participants: A sample of convenience of 14 patients (54.7 ± 10.9yrs) with a hemiparesis for less than 5 months and 11 healthy controls (50.6 ± 11.6yrs).Main Outcome Measures: The contribution of passive stiffness to the plantarflexor moment during gait was obtained using moment-angle slope (stiffness) values. Total plantarflexor stiffness was measured during gait, and passive stiffness was measured during passive dorsiflexion imposed by an isokinetic dynamometer at velocities and ranges of movement matched with values recorded during the plantarflexor lenghtening period of the stance phase. The contribution of passive stiffness was obtained by dividing the passive stiffness (dynamometer) by the total plantarflexor stiffness (gait).Results: On the paretic side, passive stiffness contributed more (16.8%; tange 2.9% to 49.6%) to total plantarflexor stiffness during gait compared (p < .01) with both the nonparetic side (7.3%) and control values (5.9%). This increased contribution on the paretic side resulted from a large muscletendon passive stiffness, a decreased active muscle contribution, or both. Although in some patients the increased passive component led to the development of a total plantarflexor stiffness that was within normal values, it did not in others either because the active component was very small or because limited dorsiflexion during the stance phase prevented the passive component tension to develop. The contribution of passive stiffness was not significantly (p > .05) related to gait speed in both the patients and the controls.Conclusions: The increased contribution of passive stiffness to total plantarflexor moment during gait likely acts as an adaptation for a defective muscle active component, helping ankle push-off at the end of the stance phase. Although this mechanism is effective in most of the patients, it cannot come into action if the dorsiflexion movement during the stance phase is prevented, for instance, by enhanced stretch reflexes.

Gait Analysis and Muscle Strength in Children with Congenital Pseudarthrosis of the Tibia: The Effect of Treatment

Twelve patients with healed congenital pseudarthrosis of the tibia underwent gait analysis and muscle strength testing to determine the functional result of treatment. Six children younger than 4 years of age presented with pseudarthroses (early onset), and six children first fractured at older than 4 years of age (delayed onset). Four children with amputations as final treatment for congenital pseudarthrosis were studied for comparison. The early-onset group had undergone an average of 4.2 surgeries and all required transankle fixation. The delayed-onset group had undergone an average of 1.5 surgeries, with one child requiring fixation across the ankle. Lack of ankle push-off and foot drop occurred in the early-onset group. Terminal stance phase ankle power generation was greatly diminished in the early-onset group. Total mechanical work performed by the affected limb, when compared to the uninvolved contralateral limb, was symmetric in delayed-onset patients and reduced by 68% in early-onset patients and by 85% in amputees. Gastrocsoleus strength was reduced by 40%. Gait and muscle strength of patients with "healed" congenital pseudarthrosis of the tibia are markedly disturbed. Early onset of disease, early surgery, and transankle fixation lead to an inefficient gait comparable to that of amputees.

Foot Trajectory in Human Gait: A Precise and Multifactorial Motor Control Task

The trajectory of the heel and toe during the swing phase of human gait were analyzed on young adults. The magnitude and variability of minimum toe clearance and heel-contact velocity were documented on 10 repeat walking trials on 11 subjects. The energetics that controlled step length resulted from a separate study of 55 walking trials conducted on subjects walking at slow, natural, and fast cadences. A sensitivity analysis of the toe clearance and heel-contact velocity measures revealed the individual changes at each joint in the link-segment chain that could be responsible for changes in those measures. Toe clearance was very small (1.29 cm) and had low variability (about 4 mm). Heel-contact velocity was negligible vertically and small (0.87 m/s) horizontally. Six joints in the link-segment chain could, with very small changes (+/- 0.86 degrees - +/- 3.3 degrees), independently account for toe clearance variability. Only one muscle group in the chain (swing-phase hamstring muscles) could be responsible for altering the heel-contact velocity prior to heel contact. Four mechanical power phases in gait (ankle push-off, hip pull-off, knee extensor eccentric power at push-off, and knee flexor eccentric power prior to heel contact) could alter step length and cadence. These analyses demonstrate that the safe trajectory of the foot during swing is a precise endpoint control task that is under the multisegment motor control of both the stance and swing limbs.

On the stability of delay equation models of simple human stretch reflexes.

Human stretch reflexes (SRs) are often too weak and ineffectual to provide adequate postural regulation or rhythmic movement boosting (e.g. in ankle pushoff at the end of stance phase in fast running). Recent improvements in methods of artificially enhancing skeletomotor responses, especially in therapeutic regimens, should not be widely employed until the clonus-resisting stability properties of SRs are better understood. We formulate an idealized linear servo model of a segmentally-mediated SR system which includes the often ignored electromechanical coupling delay. For typical closed-loop (delay/gain) ratios, the model is shown to be unstable for all values of loop gain when operating as a position servo, but maximally stable when operating as a velocity servo. We claim that the velocity servo or more of its nonlinear relatives is a better model for some well studied SRs than, e.g., Houk's stiff muscle hypothesis. We also present evidence that even feeble and quickly saturating monosynaptic postural servos are always unstable if operated as pure position regulators.