Postural Control Research Articles

Neuronal Control of Posture in Blind Individuals

The control of posture is guided by the integration of sensory information. Because blind individuals cannot apply visual information to control posture as sighted individuals do they must compensate by the remaining senses. We therefore hypothesize that blind individuals alter their brain activation in the sensorimotor cortex during postural control to compensate for balance control without vision by the increased integration of somatosensory information. Ten blind and ten sighted (matched) individuals controlled posture during conditions with (I) eyes closed / open, and (II) stable / unstable surface conditions. Postural sway was recorded by applying a pressure distribution measuring plate. Brain activation was collected by functional Near InfraRed Spectroscopy (fNIRS) above motor-sensory cortices of the right and left hemispheres. Blind individuals showed significantly increased postural sway when balancing with open eyes on an unstable surface and when compared to sighted individuals. Whereas blind individuals showed significantly increased brain activation when balancing with open eyes on stable and unstable surface conditions, sighted individuals increased their brain oxygenation only during closed eyes and unstable surface conditions. Overall conditions, blind individuals presented significantly increased brain activation in two channels of the left and right hemispheric motor-sensory cortex when compared to sighted individuals. We therefore conclude that sighted individuals increase their brain oxygenation in the sensorimotor cortex during postural control tasks that demand sensory integration processes. Blind individuals are characterized by increased brain activation overall conditions indicating additional sensory integration during postural control. Thus, the sensorimotor cortex of blind individuals adapts to control posture without vision.

Anticipatory postural adjustments during an archery performance

AbstractThe present study investigated whether there is an anticipatory postural adjustment (APA) prior to the onset of predictable perturbation generated by a releasing in the archery performance task. Eighteen volunteers were divided into two groups (expert vs. novice) depending on skill levels. Participants stood on a force plate holding a bow with a laser pointer and took a full drawing motion aiming the laser pointer to the center of target, placed 10 m away from the force plate, then released motion was performed based on the individual's preferred timing. Motion capture system measured the bow motion in 3D, two force plates estimated center of pressure (COP) displacements, and electromyographic (EMG) recorded eight lower limb muscles during the anticipatory and compensatory phases of postural control. The results revealed that, compared to the novice group, (1) the expert group showed smaller variability of bow motion, (2) the APA patterns of the COP and muscle activities before the onset of perturbation (releasing), and (3) shorter time interval between the perturbation onset and the COP peak displacement. The findings suggest that a long‐term practice results in the experts could be adopted to use APA generating mechanical benefit to compensate for predictable perturbation. This would be able to lead to a more stable subsequent postural control to realize the task goal.

Principal Component Analysis Enhanced with Bootstrapped Confidence Interval for the Classification of Parkinsonian Patients Using Gaussian Mixture Model and Gait Initiation Parameters.

Parkinson's disease is one of the major neurodegenerative diseases that affects the postural stability of patients, especially during gait initiation. There is actually an increasing demand for the development of new non-pharmacological tools that can easily classify healthy/affected patients as well as the degree of evolution of the disease. The experimental characterization of gait initiation (GI) is usually done through the simultaneous acquisition of about 20 variables, resulting in very large datasets. Dimension reduction tools are therefore suitable, considering the complexity of the physiological processes involved. The principal Component Analysis (PCA) is very powerful at reducing the dimensionality of large datasets and emphasizing correlations between variables. In this paper, the Principal Component Analysis (PCA) was enhanced with bootstrapping and applied to the study of the GI to identify the 3 majors sets of variables influencing the postural control disability of Parkinsonian patients during GI. We show that the combination of these methods can lead to a significant improvement in the unsupervised classification of healthy/affected patients using a Gaussian mixture model, since it leads to a reduced confidence interval on the estimated parameters. The benefits of this method for the identification and study of the efficiency of potential treatments is not addressed in this paper but could be addressed in future works.

Intrinsic ankle stiffness is associated with paradoxical calf muscle movement but not postural sway or age.

Due to Achilles tendon compliance, passive ankle stiffness is insufficient to stabilise the body when standing. This results in 'paradoxical' muscle movement, whereby calf muscles tend to shorten during forward body sway. Natural variation in stiffness may affect this movement. This may have consequences for postural control, with compliant ankles placing greater reliance upon active neural control rather than stretch reflexes. Previous research also suggests ageing reduces ankle stiffness, possibly contributing to reduced postural stability. Here we determine the relationship between ankle stiffness and calf muscle movement during standing, and whether this is associated with postural stability or age. Passive ankle stiffness was measured during quiet stance in 40 healthy volunteers ranging from 18 to 88years of age. Medial gastrocnemius muscle length was also recorded using ultrasound. We found a significant inverse relationship between ankle stiffness and paradoxical muscle movement, that is, more compliant ankles were associated with greater muscle shortening during forward sway (r≥0.33). This was seen during both quiet stance as well as voluntary sway. However, we found no significant effects of age upon stiffness, paradoxical motion or postural sway. Furthermore, neither paradoxical muscle motion nor ankle stiffness was associated with postural sway. These results show that natural variation in ankle stiffness alters the extent of paradoxical calf muscle movement during stance. However, the absence of a clear relationship to postural sway suggests that neural control mechanisms are more than capable of compensating for a lack of inherent joint stiffness.

Relationship between foot morphologic characteristic and postural control after jump-landing in youth competitive athletes.

Foot arch dynamics play an important role in dynamic postural control. Association between foot arch dynamics and postural control among adolescent athletes remains poorly explored. To examine the relationship between foot arch dynamics, intrinsic foot muscle (IFM) morphology, and toe flexor strength and dynamic postural stability after jump landing and repetitive rebound jump performance in competitive adolescent athletes. Based on foot arch dynamics, evaluated from relative change in the foot arch height in sitting and standing positions, 50 adolescent athletes were classified as stiff, normal, or flexible. IFM morphology was evaluated by ultrasonography. Dynamic postural stability index (DPSI) was measured as participants jumped and landed with the right leg onto a force plate, whereas repetitive rebound jumping performance was assessed using the jump height and reactive jump index. The stiff group had a significantly worse DPSI and vertical stability index than the normal group (p= 0.26, p= 0.44, respectively), and worse anteroposterior stability index (APSI) values than the flexible group (p= 0.005). Multivariate regression models of the relationship between the APSI and foot arch dynamics showed adequate power (probability of error = 0.912). Increased foot arch stiffness negatively affects dynamic balance during jump-landing, which may deteriorate their performance.

Effects of ankle joint mobilization on dynamic balance muscle activity and dynamic balance in persons with chronic ankle instability - Feasibility of a cross-over study

IntroductionStudies with focus on effects of manual therapy techniques on postural control and muscle activity in patients with chronic ankle instability (are lacking. The purpose of this study was to evaluate the feasibility of a planned cross-over study to assess efficacy of manual therapy techniques applications in patients with chronic ankle instability. MethodsThis feasibility study used a randomized controlled, blinded assessor cross-over design. Criteria of success under evaluation were adherence and attrition rates and adverse events. while preliminary treatment effects of manual therapy techniques on muscular activity (measured by surface electromyography) and on dynamic balance (measured by time to stabilization test) were secondary aims. ResultsThirteen participants (mean age: 24.4 ± 3.8 years) with chronic ankle instability volunteered in this feasibility study. Success criteria showed a high adherence (98.7%) and low attrition (0%). No missing data were reported but four out of 26 data sets could not be used for statistical analysis because of non-readability of the recorded data. Preliminary treatment effect showed divergent results for surface electromyography and time to stabilization. One significant result (p = 0.03, ES = 1.48) in peroneus longus muscle activity after jump landing between 30 and 60 ms could be determined. ConclusionsThis study showed that the study protocol is feasible but should be modified by offering participants the opportunity to familiarize to the jumps and to the test repetitions. This study generates better understanding of manual therapy techniques for patients with chronic ankle instability.

Generalization of In-Place Balance Perturbation Training in People With Parkinson Disease.

Reactive balance training improves reactive postural control in people with Parkinson disease (PwPD). However, the extent to which reactive balance training generalizes to a novel, unpracticed reactive balance task is unknown. This study aimed to determine whether reactive training stepping through support surface translations can be generalized to an unpracticed, instrumented tether-release task. Twenty-five PwPD (70.52years±7.15; Hoehn and Yahr range 1-3) completed a multiple baseline, open-label, uncontrolled pre-post intervention study. Stepping was trained through a 2-week (6-session) intervention with repeated support surface translations. Performance on an untrained tether-release task (generalization task) was measured at 2 baseline assessments (B1 and B2, 2 weeks apart), immediately after the intervention (P1), and 2 months after training (P2). The tether-release task outcomes were the anterior-posterior margin of stability (MOS), step length, and step latency during backward and forward steps. After support surface translation practice, tether-release stepping performance improved in MOS, step length, and step latency for both backward and forward steps compared to baseline ( P <0.05). Improvements in MOS and step length during backward and forward steps in the tether-release task, respectively, were related to stepping changes in the practiced task. However, the improvements in the generalization task were not retained for 2 months. These findings support short-term generalization from trained balance tasks to novel, untrained tasks. These findings contribute to our understanding of the effects and generalization of reactive step training in PwPD. for more insights from the authors (see the Video, Supplemental Digital Content available at http://links.lww.com/JNPT/A465 ).

Sensory function and somatosensorial system changes according to visual acuity and throwing techniques in goalball players: A cross-sectional study.

The somatosensory system is a complect sensory system that differentiates individual athletes. The aim of this study is to investigate the effect of visual acuity level on throwing technique, proprioceptive sense of the shoulder joint, light touch and two-point discrimination sense of the upper extremity, and sensory function (postural control and reaction time) in visually impaired goalball players. Goalball players who have different visual acuities B1(unable to perceive light or recognize its shape); B2 (has a visual field of less than 5 degrees and can recognize shapes); B3 (visual field greater than 5 degrees and less than 20 degrees) participated in the study. The sensorial system was evaluated with proprioceptive sense of the shoulder joint and sensory tests (light touch and two-point discrimination sense of the dominant hand.). Sensory function (postural control and reaction time) was evaluated with the flamingo balance test, functional reach test, and pro-agility test. The goalball players' throwing technique was questioned. Seventeen male players, those aged 20-30 (20.8±3.9 years) who have been professionally engaged in goalball for at least three years (58.7-37.8 months) participated. Shoulder internal rotation joint position sense and the flamingo balance test were found to be different in the group with B1 visual acuity than in the group with B3 visual acuity (p = 0.042* and 0.028 respectively). There was no difference between groups with B1-B2 visual acuity (p = 0.394 and p = 0.065) and between groups with B2-B3 visual acuity (p = 0.792 and p = 0.931). There was no difference in the groups in terms of sensory tests and reaction time (p> 0.05). In goalball, joint position sense is related to throwing techniques. Although there is a general acceptance that other sensory systems should work harder to compensate for the sense of vision, fear of falling, athlete's branch year, sports year, muscle strength, and general physical condition of the athlete may affect the measurements made, especially in the dynamic position.

Ground reaction forces better than center of pressure differentiate postural control between young female volleyball players and untrained peers

A comprehensive explanation of the relationship between postural control and athletic performance requires compare body balance in athletes with their never training counterparts. To fill this gap in relation to volleyball, the aim of this study was to compare the balance of intermediate adolescent female players (VOL, n = 61) with inactive peers (CON, n = 57). The participants were investigated in normal quiet stance during 20 s trials on a Kistler force plate. The traditional spatial (amplitude and mean speed) and temporal (frequency and entropy) indices were computed for ground reaction forces (GRF) and center-of-pressure (COP) time-series. The spatial parameters of the both time-series did not discriminate the two groups. However, the temporal GRF parameters revealed much lower values in VOL than in CON (p < .0001). This leads to three important conclusions regarding posturography applications. First, GRF and COP provide different information regarding postural control. Second, measures based on GRF are more sensitive to changes in balance related to volleyball training and perhaps to similar training and sports activity regimens. And third, the indicators calculated based on these two time series can complement each other and thus enrich the insight into the relationship between balance and sports performance level.

Physiotherapy for Alzheimer’s Disease: A Case Report

Alzheimer's disease is a progressive neurological condition characterized by brain changes resulting in the accumulation of specific proteins, leading to brain shrinkage and eventual cell death. It is the primary cause of dementia, resulting in a gradual decline in memory, cognition, behaviour, and social skills, impairing overall functionality. The case study involves an 84-year-old woman displaying symptoms of Alzheimer's disease requiring physiotherapy rehabilitation. Assessment reveals joint pain, abnormal gait, respiratory issues due to pneumonia, reduced balance and cognitive function, concentration difficulties, impaired decision-making, fluctuating moods, and behavioural issues such as depression and aggression. Physical examination shows shoulder shrugging and slight tension in the upper trapezius muscle. The rehabilitation program involves various interventions like stretching, strengthening, aerobic exercises, breathing exercises, lung clearance techniques, active range of motion exercises, postural control, and gait training. The role of the physiotherapist is to address the both physical and cognitive decline and improve mood and behaviour.

Different Dual-Task Paradigm Reduce Postural Control Ability and Dynamic Stability of Healthy Young Adults during Stair Descent.

This study aimed to compare the impacts of different dual-task paradigms on the postural control ability and dynamic stability of the youth during stair descent. Twenty young adults without regular exercise habits were randomly recruited to perform stair descent tasks with three different paradigms: single-task, cognitive dual-task, and manual dual-task. Kinematic and dynamic data were collected using an 8 Vicon motion analysis system and a Kistler force plate to evaluate postural control ability and dynamic stability during stair descent. The variation trends of lower limb joint moment were similar under the three task models. Compared with a single-task, both dual-task paradigms significantly reduced the mechanical parameters and dynamic stability during stair descent. The dual-task paradigm increases the risk of stair-related falls. Both cognitive and manual tasks have similar impacts on postural control ability and dynamic stability during stair walking. It is recommended that people avoid performing dual tasks during stair descent.

Towards a better understanding of anticipatory postural adjustments in people with Parkinson's disease.

Previous studies have shown that anticipatory postural adjustments (APAs) are altered in people with Parkinson's disease but its meaning for locomotion is less understood. This study aims to investigate the association between APAs and gait initiation, gait and freezing of gait and how a dynamic postural control challenging training may induce changes in these features. Gait initiation was quantified using wearable sensors and subsequent straight walking was assessed via marker-based motion capture. Additionally, turning and FOG-related outcomes were measured with wearable sensors. Assessments were conducted one week before (Pre), one week after (Post) and 4 weeks after (Follow-up) completion of a training intervention (split-belt treadmill training or regular treadmill training), under single task and dual task (DT) conditions. Statistical analysis included a linear mixed model for training effects and correlation analysis between APAs and the other outcomes for Pre and Post-Pre delta. 52 participants with Parkinson's disease (22 freezers) were assessed. We found that APA size in the medio-lateral direction during DT was positively associated with gait speed (p<0.001) and stride length (p<0.001) under DT conditions at Pre. The training effect was largest for first step range of motion and was similar for both training modes. For the associations between changes after the training (pooled sample) medio-lateral APA size showed a significant positive correlation with first step range of motion (p = 0.033) only in the DT condition and for the non-freezers only. The findings of this work revealed new insights into how APAs were not associated with first step characteristics and freezing and only baseline APAs during DT were related with DT gait characteristics. Training-induced changes in the size of APAs were related to training benefits in the first step ROM only in non-freezers. Based on the presented results increasing APA size through interventions might not be the ideal target for overall improvement of locomotion.

Associations between biological maturation, physical performance, postural control, and mathematical achievement in youth soccer players.

This investigation explored relationships between biological maturation, physical and academic performance in young male soccer players. Thirty-eight players (age: 9.79 ± 1.21 years; body mass index (BMI): 20.4 ± 2.39 kg/m2; body fat: 16.8 ± 2.21%) participated. Measures of anthropometry used for body mass, body fat percentage (%BF), and BMI as well. Postural control, 15 m sprint, squat jumps and counter-movement jumps (SJ, CMJ), and T-half test for change-of-direction (CoD) were parameters of physical performance. The grade point average (GPA) of mathematics determined academic attainment. Moore's equations were used to estimate their maturity status (PHV). Biological maturation was highly correlated with most (not 15 m sprint) physical and academic performance parameters, especially CMJ (r = -0.812) and mathematics (r = -0.781). Academic performance showed the largest relations to the jumping performance (CMJ: r = 0.771; SJ: r = 0.723). In contrast, anthropometric and fatness parameters were not relevantly (r ≥ 0.5) correlated with any other parameters. The largest correlations were calculated for sitting height vs. SJ (r = -0.408), sitting height vs. postural control (r = -0.355), leg length vs. postural control (r = -0.339). As a result, it is essential to take biological maturation inconsideration while assessing the physical and academic achievement of young soccer players. In consequence, soccer coaches and physical education (PE) teachers should be cognizant of the impact of biological maturity on physical and academic performance to assist fair and equal opportunities for achievement in young players.

Differences in pre-season balance among student athletes based on level of contact, age, and sex

BackgroundAssessing postural control is important for the assessment of motor function after concussion. Data used for postural control assessment typically do not take the sport played, age, or sex of the athlete into consideration. It is plausible these variables may be significant when making return-to-play decisions. Research questionThis study used the BTrackS database to examine differences in postural control in athletes playing different types of sports and across sex and age. MethodsBTrackS data from 9093 high school to college-aged athletes (aged 14–22 years) were examined employing a One-way ANOVA with a post-hoc test to compare CoP path length between sport types. A moderation analysis was used to test interaction effects of sex and age on a CoP/BMI ratio. ResultsSignificant differences were observed between sport types, F(3,9089) = 42.4, p <.001, η2 = 0.014. Post hoc tests indicated that collision (M = 25.0, SD = 7.6) sport athletes exhibited significantly higher CoP measures compared to the contact (M = 23.4, SD = 7.4), limited contact (M = 22.9, SD = 6.9), and non-contact (M = 23.0, SD = 7.4) athletes. There was no difference between other sport types (p >.20). A significant mean sex difference (Mmale = 0.924, Mfemale = 0.898, p <.001) and a quadratic association with age, (β = −0.042, p <.001) was observed. Further, magnitude of those age differences decreased with age (β = 0.011, p <.001). An interaction of age and sex was significant for linear (β = 0.020, p <.001) and quadratic terms (β = −0.006, p <.001). SignificanceAthletes exhibited different postural control when the type of sport, age, and sex was taken into consideration. This data possess clinical significance as this suggests that normative postural control data for collision sport athletes should be derived from data based upon type of sport played, age, and sex of the athlete.

Enhancing Tractor Stability and Safety through Individual Actuators in Active Suspension

Tractor overturning accidents are a prominent safety concern in the field of agriculture. Many studies have been conducted to prevent tractor overturning accidents. Rollover protective structures and seat belts currently installed on tractors cannot prevent them from overturning. The posture of a tractor was controlled by installing individual actuators. The overturning angles of the tractor equipped with an actuator were compared with those of a tractor with no actuator. For the overturning angles in all directions of the tractor, it rotated 15° from 0° to 345°, and the actuator height suitable for the tractor posture was controlled by establishing an equation according to the tractor posture. Consequently, posture control using actuators was noticeably improved. This study proposes that tractors operating on irregular and sloping terrain be equipped with individual actuators. These results prevent tractor rollover accidents and improve safety and driving stability.

Postural Control and Sensory Processing in Preschool Children with Autistic Spectrum Disorder: A Cross-Sectional Study.

The role of sensory processing in maintaining postural control (PC) among preschool-aged children with autism spectrum disorder (ASD) remains underexplored despite its potential implications for their developmental trajectory. This study aimed to assess the utilization of sensory information for PC maintenance while standing in preschool-aged children with ASD and to examine its correlation with PC during functional tasks using a standardized tool. The cross-sectional study recruited 27 children, aged between 3 and 6 years, diagnosed with ASD. Participation indexes for somatosensory, vestibular, visual, and visual preference were computed during a modified Clinical Test of Sensory Integration and Balance (m-CTSIB), based on sagittal plane body sway analyzed via video with Kinovea® software (version 0.9.4). Additionally, scores from the Pediatric Balance Scale (PBS) were analyzed. Statistical analysis of data derived from lateral malleolus and mastoid process sway using the Friedman test revealed significant differences in the utilization of various sensory systems involved in PC during the m-CTSIB (p < 0.001). There was a pronounced reliance on somatosensory information, coupled with increased instability in the absence or with the variability of visual information. The mean PBS score was 50.44 ± 2.74, exhibiting a significant negative correlation with the vestibular index (p < 0.05). Preschool-aged children with ASD demonstrated challenges in maintaining PC while standing under different sensory conditions, indicating a heightened dependence on somatosensory cues, particularly in the absence or with the variability of visual stimuli. While these challenges were not reflected in PBS scores, they were negatively correlated with the vestibular index.

Extracorporeal Shock Wave Therapy with Low-Energy Flux Density Treatment Applied to Hemiplegia Patients on Somatosensory Functions and Spatiotemporal Parameters.

We aimed to investigate the efect of Extracorporeal Shock Wave Therapy (ESWT) applied to patients with hemiplegia on somatosensory data, spatiotemporal parameters, posture, and muscle tone. This was a double-blind, randomised, controlled trial. Patients were randomised within pairs to either the experimental (ESWT) group (n=20) or the control group (n=20). All patients participated in the same conventional stroke rehabilitation program for 60 minutes of treatment a day, 5 times a week for 6 weeks (30 sessions). Patients assigned to the ESWT group received additional ESWT over the plantar fascia 3 days/week for 6 weeks. Timed Up and Go (TUG) test, Modified Ashworth Scale (MAS) score, Posture Assessment Scale for Stroke Patients (PASS), spatiotemporal parameters, Semmes-Weinstein monofilament (SWM) test, and vibration sensation test (VST) were performed in all participant before and after treatment. In the ESWT and control groups, statistically, significant diferences were obtained in the posttreatment analysis than pre-treatment. Significant diferences were found in foot angle, step cycle duration, swing phase, cadence, gait cycle distance, and VST values after ESWT treatment (P < .01). When combined with a neurological rehabilitation program, it was determined that ESWT applied to the plantar face of the foot in individuals with hemiplegia increased somatosensory functions and was more successful in developing postural control and balance.

Investigating Biomechanical Postural Control Strategies in Healthy Aging Adults and Survivors of Stroke

As the aging populations, both nationwide and worldwide, rapidly increase, falls leading to unintentional injury and death subsequently increase. Thus, developing an understanding of biomechanical postural control strategies used to maintain balance in aging healthy adults, and those that have suffered stroke, are critical. Here, we were interested in how one’s body segments stabilize relative to one another, and in space, in order to maintain balance. To accomplish this goal, we studied 30 healthy individuals and 8 survivors of stroke between 60 and 85 years old, both before and after several weeks of sensory training. Motion capture data were acquired to assess participants’ body kinematics during walking: forward (easiest), forward-tandem, backward, and backward-tandem walking (most challenging). Deviations (via the observation of the absolute angle with deviations, or AADs) of the head, thorax, and lumbar areas relative to an earth vertical reference, as well as how one body segment stabilized in space or relative to the inferior body segment (via the observation of anchoring indices, or AIs), were explored. The results provide metrics (AADs and AIs) that can assess aging posture. Further, the results show an initial indication that, for aging individuals, training could lead to improved head and body stabilization in space.

Impact of sensory reweighting strategies on postural control using the sensory organization test in older adults with and without fall risks.

The Sensory Organization Test (SOT), an integral part of computerized dynamic posturography, plays a crucial role in evaluating postural stability under various altered sensory conditions. Despite its importance, there have been noted inconsistencies in the results pertaining to equilibrium and sensory system evaluations. This study aimed to compare four sensory analysis scores and equilibrium indices between older adults with and without fall risks. The study included 34 participants identified as being at risk of falls and 42 control subjects. To categorize individuals between the two groups, we performed area under the receiver operating characteristic curve analyses. This classification was based on scores from the Modified Falls Efficacy Scale (MFES) and the composite scores obtained from the SOT. In addition, we used the Tampa Scale for Kinesiophobia (TSK) as well as the level of disability. The fall risk group demonstrated significantly higher TSK scores (39.39± 15.24 for control group vs. 54.65±10.70 for fall risk group; t=-5.09, p=0.001). The groups demonstrated a significant interaction on the equilibrium index (F=4.59, p=0.03), which was lower in the fall risk group in Condition 6 with a moving surface and surround and eyes open (t=2.29, p=0.01). The fall risk group demonstrated a higher somatosensory score (t=-1.73, p=0.04). The fall risk group had a lower equilibrium index score in Condition six of the SOT, which was useful for identifying deficits in vestibular function to integrate sensory information under challenging conditions for postural adaptation. This strategy suggested that the fall risk group could compensate for their risk of falls by utilizing more effective somatosensory reweighting strategies compared with the control group.

Muscle-inspired bi-planar cable routing: a novel framework for designing cable driven lower limb rehabilitation exoskeletons (C-LREX)

There is a growing interest in the research and development of Cable Driven Rehabilitation Devices (CDRDs) due to multiple inherent features attractive to clinical applications, including low inertia, lightweight, high payload-to-weight ratio, large workspace, and modular design. However, previous CDRDs have mainly focused on modifying motor impairment in the sagittal plane, despite the fact that neurological disorders, such as stroke, often involve postural control and gait impairment in multiple planes. To address this gap, this work introduces a novel framework for designing a cable-driven lower limb rehabilitation exoskeleton which can assist with bi-planar impaired posture and gait. The framework used a lower limb model to analyze different cable routings inspired by human muscle architecture and attachment schemes to identify optimal routing and associated parameters. The selected cable routings were safeguarded for non-interference with the human body while generating bi-directional joint moments. The subsequent optimal cable routing model was then implemented in simulations of tracking reference healthy trajectory with bi-planar impaired gait (both in the sagittal and frontal planes). The results showed that controlling joints independently via cables yielded better performance compared to dependent control. Routing long cables through intermediate hinges reduced the peak tensions in the cables, however, at a cost of induced additional joint forces. Overall, this study provides a systematic and quantitative in silico approach, featured with accessible graphical user interface (GUI), for designing subject-specific, safe, and effective lower limb cable-driven exoskeletons for rehabilitation with options for multi-planar personalized impairment-specific features.