title: Stance controlled knee flexion improves stimulation driven walking after spinal cord injury.
abstract: BACKGROUND
  Functional neuromuscular stimulation (FNS) restores walking function after paralysis from spinal cord injury via electrical activation of muscles in a coordinated fashion. Combining FNS with a controllable orthosis to create a hybrid neuroprosthesis (HNP) has the potential to extend walking distance and time by mechanically locking the knee joint during stance to allow knee extensor muscle to rest with stimulation turned off. Recent efforts have focused on creating advanced HNPs which couple joint motion (e.g., hip and knee or knee and ankle) to improve joint coordination during swing phase while maintaining a stiff-leg during stance phase.
  
  
  METHODS
  The goal of this study was to investigate the effects of incorporating stance controlled knee flexion during loading response and pre-swing phases on restored gait. Knee control in the HNP was achieved by a specially designed variable impedance knee mechanism (VIKM). One subject with a T7 level spinal cord injury was enrolled and served as his own control in examining two techniques to restore level over-ground walking: FNS-only (which retained a stiff knee during stance) and VIKM-HNP (which allowed controlled knee motion during stance). The stimulation pattern driving the walking motion remained the same for both techniques; the only difference was that knee extensor stimulation was constant during stance with FNS-only and modulated together with the VIKM to control knee motion during stance with VIKM-HNP.
  
  
  RESULTS
  Stance phase knee angle was more natural during VIKM-HNP gait while knee hyperextension persisted during stiff-legged FNS-only walking. During loading response phase, vertical ground reaction force was less impulsive and instantaneous gait speed was increased with VIKM-HNP, suggesting that knee flexion assisted in weight transfer to the leading limb. Enhanced knee flexion during pre-swing phase also aided flexion during swing, especially when response to stimulation was compromised.
  
  
  CONCLUSIONS
  These results show the potential advantages of incorporating stance controlled knee flexion into a hybrid neuroprosthesis for walking. The addition of such control to FNS driven walking could also enable non-level walking tasks such as uneven terrain, slope navigation and stair descent where controlled knee flexion during weight bearing is critical.
authors.affiliation: Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA. thomas.bulea@case.edu
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Bulea
authors.forename: Rudi
authors.initials: R
authors.lastname: Kobetic
authors.forename: Musa L
authors.initials: ML
authors.lastname: Audu
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Triolo
mesh_terms: D001696:Biomechanical Phenomena; D006801:Humans; D007719:Knee Joint / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D058117:Neural Prostheses; D010243:Paralysis / Q000209:etiology / Q000534:rehabilitation; D011474:Prosthesis Design; D013119:Spinal Cord Injuries / Q000150:complications / Q000534:rehabilitation*; D016138:Walking / Q000502:physiology*