title: The effects of powered ankle-foot orthoses on joint kinematics and muscle activation during walking in individuals with incomplete spinal cord injury.
abstract: BACKGROUND
  Powered 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.
  
  
  METHODS
  Five 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.
  
  
  RESULTS
  A therapist quickly learned to activate the artificial pneumatic muscles using the pushbuttons with the appropriate amplitude and timing. The powered orthoses provided approximately 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 (approximately 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 (approximately 31% lower for therapist-controlled; p < 0.05).
  
  
  CONCLUSIONS
  Mechanical 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.
authors.affiliation: Division of Kinesiology, University of Michigan, Ann Arbor, MI, USA. gsawicki@umich.edu
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Sawicki
authors.forename: Antoinette
authors.initials: A
authors.lastname: Domingo
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Ferris