Individual stiffness optimization of dorsal leaf spring ankle–foot orthoses in people with calf muscle weakness is superior to standard bodyweight-based recommendations

Background In people with calf muscle weakness, the stiffness of dorsal leaf spring ankle–foot orthoses (DLS-AFO) needs to be individualized to maximize its effect on walking. Orthotic suppliers may recommend a certain stiffness based on body weight and activity level. However, it is unknown whether these recommendations are sufficient to yield the optimal stiffness for the individual. Therefore, we assessed whether the stiffness following the supplier’s recommendation of the Carbon Ankle7 (CA7) dorsal leaf matched the experimentally optimized AFO stiffness. Methods Thirty-four persons with calf muscle weakness were included and provided a new DLS-AFO of which the stiffness could be varied by changing the CA7® (Ottobock, Duderstadt, Germany) dorsal leaf. For five different stiffness levels, including the supplier recommended stiffness, gait biomechanics, walking energy cost and speed were assessed. Based on these measures, the individual experimentally optimal AFO stiffness was selected. Results In only 8 of 34 (23%) participants, the supplier recommended stiffness matched the experimentally optimized AFO stiffness, the latter being on average 1.2 ± 1.3 Nm/degree more flexible. The DLS-AFO with an experimentally optimized stiffness resulted in a significantly lower walking energy cost (− 0.21 ± 0.26 J/kg/m, p < 0.001) and a higher speed (+ 0.02 m/s, p = 0.003). Additionally, a larger ankle range of motion (+ 1.3 ± 0.3 degrees, p < 0.001) and higher ankle power (+ 0.16 ± 0.04 W/kg, p < 0.001) were found with the experimentally optimized stiffness compared to the supplier recommended stiffness. Conclusions In people with calf muscle weakness, current supplier’s recommendations for the CA7 stiffness level result in the provision of DLS-AFOs that are too stiff and only achieve 80% of the reduction in energy cost achieved with an individual optimized stiffness. It is recommended to experimentally optimize the CA7 stiffness in people with calf muscle weakness in order to maximize treatment outcomes. Trial registration Nederlands Trial Register 5170. Registration date: May 7th 2015. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170.

Energy Expenditure of Level Overground Walking in Young Adults: Comparison With Prediction Equations

Background: The purpose of this study was to investigate the accuracy of the published prediction equations for determining level overground walking energy cost in young adults. Methods: In total, 148 healthy young adults volunteered to participate in this study. Resting metabolic rate and energy expenditure variables at speeds of 4, 5, and 6 km/h were measured by indirect calorimetry, walking energy expenditure was estimated by 3 published equations. Results: The gross and net metabolic rate per mile of level overground walking increased with increased speed (all P < .01). Females were less economical than males. The present findings revealed that the American College of Sports Medicine and Pandolf et al equations significantly underestimated the energy cost of overground walking at all speeds (all P < .01) in young adults. The percentage mean bias for American College of Sports Medicine, Pandolf et al, and Weyand et al was 12.4%, 16.8%, 1.4% (4 km/h); 21.6%, 15.8%, 7.1% (5 km/h); and 27.6%, 12%, 6.6% (6 km/h). Bland–Altman plots and prediction error analysis showed that the Weyand et al was the most accurate in 3 existing equations. Conclusions: The Weyand et al equation appears to be the most suitable for the prediction of overground walking energy expenditure in young adults.

Modifying ankle foot orthosis stiffness in patients with calf muscle weakness: gait responses on group and individual level

Background To improve gait, persons with calf muscle weakness can be provided with a dorsal leaf spring ankle foot orthosis (DLS-AFO). These AFOs can store energy during stance and return this energy during push-off, which, in turn, reduces walking energy cost. Simulations indicate that the effect of the DLS-AFO on walking energy cost and gait biomechanics depends on its stiffness and on patient characteristics. We therefore studied the effect of varying DLS-AFO stiffness on reducing walking energy cost, and improving gait biomechanics and AFO generated power in persons with non-spastic calf muscle weakness, and whether the optimal AFO stiffness for maximally reducing walking energy cost varies between persons. Methods Thirty-seven individuals with neuromuscular disorders and non-spastic calf muscle weakness were included. Participants were provided with a DLS-AFO of which the stiffness could be varied. For 5 stiffness configurations (ranging from 2.8 to 6.6 Nm/degree), walking energy cost (J/kg/m) was assessed using a 6-min comfortable walk test. Selected gait parameters, e.g. maximal dorsiflexion angle, ankle power, knee angle, knee moment and AFO generated power, were derived from 3D gait analysis. Results On group level, no significant effect of DLS-AFO stiffness on reducing walking energy cost was found (p = 0.059, largest difference: 0.14 J/kg/m). The AFO stiffness that reduced energy cost the most varied between persons. The difference in energy cost between the least and most efficient AFO stiffness was on average 10.7%. Regarding gait biomechanics, increasing AFO stiffness significantly decreased maximal ankle dorsiflexion angle (− 1.1 ± 0.1 degrees per 1 Nm/degree, p < 0.001) and peak ankle power (− 0.09 ± 0.01 W/kg, p < 0.001). The reduction in minimal knee angle (− 0.3 ± 0.1 degrees, p = 0.034), and increment in external knee extension moment in stance (− 0.01 ± 0.01 Nm/kg, p = 0.016) were small, although all stiffness’ substantially affected knee angle and knee moment compared to shoes only. No effect of stiffness on AFO generated power was found (p = 0.900). Conclusions The optimal efficient DLS-AFO stiffness varied largely between persons with non-spastic calf muscle weakness. Results indicate this is caused by an individual trade-off between ankle angle and ankle power affected differently by AFO stiffness. We therefore recommend that the AFO stiffness should be individually optimized to best improve gait. Trial registration number Nederlands Trial Register 5170. Registration date: May 7th 2015. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170

Effects of Load Connection Form on Efficiency and Kinetics of Biped Walking

This paper investigates the influence of the load connection form on the walking energetics and kinetics with simple models. Four load connection forms including rigid connection (RIC), springy connection (SPC), swingy connection (SWC), and springy and swingy connection (SSC) were modeled. The step-to-step transition of periodic walking was studied through an analytical method. The toe-off impulse magnitude and the work done by toe-off were derived. Simulations were performed to study the walking performance of each model and the effect of model parameters on the gait properties. The analysis and simulation results showed that compared with RIC, SPC and SSC can significantly improve the toe-off efficiency and change the ground reaction force (GRF) profile by reducing the burden during the step-to-step transition, which may lead to reduction of walking energy cost. Energetics and kinetics of SWC are closely related to the swing angle of load at the transition moment. The load swing may decrease the walking speed, and it is not beneficial to walking efficiency.

Defining the Mechanical Properties of a Spring-hinged Ankle Foot Orthosis to Assess its Potential Use in Children With Spastic Cerebral Palsy

A rigid ventral shelf ankle foot orthosis (AFO) may improve gait in children with spastic cerebral palsy (SCP) whose gait is characterized by excessive knee flexion in stance. However, these AFOs can also impede ankle range of motion (ROM) and thereby inhibit push-off power. A more spring-like AFO can enhance push-off and may potentially reduce walking energy cost. The recent development of an adjustable spring-hinged AFO now allows adjustment of AFO stiffness, enabling tuning toward optimal gait performance. This study aims to quantify the mechanical properties of this spring-hinged AFO for each of its springs and settings. Using an AFO stiffness tester, two AFO hinges and their accompanying springs were measured. The springs showed a stiffness range of 0.01−1.82 N·m·deg−1. The moment-threshold increased with increasing stiffness (1.13–12.1 N·m), while ROM decreased (4.91–16.5°). Energy was returned by all springs (11.5–116.3 J). These results suggest that the two stiffest available springs should improve joint kinematics and enhance push-off in children with SCP walking with excessive knee flexion.