Development of an Active Ankle Foot Orthosis for the Prevention of Foot Drop and Toe Drag

Sungjae Hwang1, Jungyoon Kim1, Jinbock Yi1,3, Kisik Tae1, Kihong Ryu1, Youngho Kim1,2
Department of Biomedical Engineering, Yonsei University, Wonju, South Korea 2 Institute of Medical Engineering, Yonsei University, Wonju, South Korea 3 Department of Prosthetics and Orthotics, Hanseo University, Seosan, South Korea younghokim@yonsei.ac.kr
AbstractIn this study, we developed an active ankle-foot orthosis (AAFO) which can control the dorsi/ plantarflexion of the ankle joint to prevent foot drop and toe drag during walking. To prevent slapping foot after heel strike, ankle joint has to be controlled actively to minimize forefoot collision with the ground. In the late stance, ankle joint also has to be controlled to provide the toe clearance and help the push-off. 3D gait analyses were performed on five healthy subjects (age: 27.52.1 years, height: 169.44.3cm, weight: 66.42.3kg) using a near-infrared 3D motion analysis system (Vicon 612, VICON, U.S.A.). Three different gait conditions were compared: the normal gait without AFO, the SAFO gait with the conventional plastic AFO, the AAFO gait with the developed AFO. As a result, the developed AAFO could preeminently induce the normal gait compared with SAFO. Additionally, AAFO can prevent the foot drop by proper plantarflexion during loading response and provide enough plantarflexion moment as driving force to walk forward by the sufficient push-off during pre-swing. AAFO also can prevent the toe drag by proper dorsiflexion during swing phase. In addition, SAFO can bring a very inefficient gait by the abnormal pelvic movement with a compensation for the limited movement of ankle joint. On the other hand, the AAFO can induce an efficient gait with the similar movement as in the normal gait. These results indicate that the developed AAFO may have more clinical benefits to treat foot drop and toe drag, compared with conventional AFOs, and also could be useful in polio patients or patients with other orthotic devices. KeywordsActive Ankle-Foot-Orthosis Plantarklexion, Foot Drop, Toe Drag , Dorsiflexion,
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clearance in swing. Carlson et al. [6] compared gait patterns before and after wearing AFO in cerebral palsy (CP) patients and reported that ankle dorsiflexion during initial contact and plantarflexion moment during initial contact and during terminal stance increased. However, walking speed and step length were not improved and ankle power reduces during late stance period. Lehmann et al. [7] reported that it prevents the toe drag during swing phase in hemiplegic patients but does not prevent the foot slap during stance phase. In addition, the conventional AFO does not generate enough ankle plantarflexion moment. Therefore, it does not guarantee weight support during loading response, shock absorption, push off, and the acceleration of the swinging leg. Functional electrical stimulation using momentary electrical pulse to induce muscle contractions has been expected as a permanent aid. However, it is not only a personal custom device through continuous trial and error, but also has muscle fatigue problems. FES walking for a long time is still limited in practice [8, 9]. Also, there are much more difficulties in automatic FES walking such as the accuracy of gait phase detection and system adaptability of the variable walking speed and patterns up to now. To prevent slapping foot after heel strike, ankle joint has to be controlled actively to minimize forefoot collision with the ground. In the late stance, ankle joint also has to be controlled to provide the toe clearance and to help the push-off. In this study an active ankle-foot orthosis (AAFO) was developed to provide proper ankle moment to prevent foot drop and toe drag based on an accurate detection of the gait phase. Then, we compared the conventional plastic AFO (SAFO) with the developed AAFO in healthy male volunteers using the 3D motion analysis system. II. METHODOLOGY

I. INTRODUCTION Foot drop and toe drag are symptoms that muscular activites around the ankle become weak due to the paralysis of the neural system [1-3]. Such patients show abnormal gait patterns in which dorsiflexion and eversion of the ankle do not occur voluntarily. Due to the spastic plantarflexor, the sole or the forefoot instead of the heel strikes the ground during initial contact period, and then the stance time shortens, and the toe drags on the ground during swing phase. Such inefficient gait patterns result in slow walking speed and increased energy consumption [4, 5]. There are two methods for improving gait pattern in patients with foot drop and toe drag: the ankle-foot orthosis (AFO) and the functional electrical stimulation (FES). Coventional AFO alone does not guarantee a perfect gait pattern, since it is used for the stability in stance and the foot

A. Design of AAFO The AAFO is largely composed of a polypropylene AFO with a hinged ankle joint, the sensor unit, the controller and the series elastic actuator. The sensor unit detects the gait phase during walking and the controller controls dorsiflexion/ plantarflexion based on the output signals from the sensors. The series elastic actuator provides the movement of an ankle joint based on signals from the controller.

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Figure 1. Block diagram of the AAFO

1) Series Elastic Actuator (SEA) The SEA controls the ankle movement of AAFO on the basis of the control signal of the motor. As shown in Fig. 2, it includes a coupling, two spring meal plates, a ball nut metal plate, a end mount, four compression springs, six bushings, one ball screw, one ball nut, two guide rails, two plunger and a connecting ring with the orthosis [10]. The ball screw and the ball nut convert rotations of a motor into translational motors. Joint motions of the AAFO can be adjusted by varying the number of revolutions and the direction of the motor. In addition, an encoder, attached to the motor, controls the operating conditions of the motor by transmitting information of the position and the speed to the slave controller. Compression springs were inserted into the series elastic actuator for minimizing the backlash caused by the motor and the shock occurred during walking. 3) Sensor In order to detect gait phases, FSR sensors (MA-152, Motion Lab System Inc., U.S.A.) and a rotary potentiometer (RV16YP-5k , Violet, Korea) were used (Fig. 4). FSR sensor was a small flat resistor whose resistance changes nonlinearly with the applied force. FSR sensors were used as ON/OFF switches to indicated ground contact measuring the voltage drop across each FSR sensor connected in a voltage divider circuit [11]. Totally four FSR sensors were placed on the heel, the hallux, 1st metatarsal head and 5th metatarsal base. A rotary potentiometer was attached to the hinged ankle joint of the AAFO to measure dorsiflexion/plantarflexion angles during walking.

Figure 3. The developed AAFO

Figure 2. Series Elastic Actuator(SEA)

2) AFO The AFO was fabricated suitably to each subject at the Dept. of Prosthetics and Orthotics, Hanseo University. A metal hinged ankle joint was used. It was designed to freely allow dorsiflexion/plantarflexion of the ankle joint but not to limit motions in the other direction. Fig. 3 shows a photo of the developed AAFO.
Figure 4. The placement of FSR snesors and a rotary potentiometer

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4) Control Unit Fig. 5 shows the block diagram of the whole control program. The control unit is composed of a master processor to detect gait phase and a slave processor to control the motor based on the detected signals. Output signals from the sensors are used as input signals of the master controller(PIC16C73) after they passed through an amplification circuit located outside. The master controller performs A/D conversion of the approved input signal, set up of FSR sensors of reference voltage and compared continuously with detected signals. Then, gait phases were determined by the gait phase detection algorithm. The signal detected through the master controller is approved as the input signal of the slave controller(PIC16C73) determining the number and direction of the motor rotation through motor control algorithm according to the determined gait phase. In addition, the slave controller controls the operation of the motor by detecting the position and the motor speed from the encoder.

T1 (swing heel strike): In the swing phase, the algorithm waits for the transition to the heel strike phase, which begins with the initial contact of the heel with the ground. T2 (heel strike foot flat): In normal situation, foot flat follows after the heel strike, which begins when both the front and rear parts of the foot contact the ground. This event is detected when the heel FSR sensor and at least one of the other three FSR sensors are ON. T3 (foot flat heel off): In the foot flat phase, the algorithm waits for the beginning of the heel off phase. The heel off phase is detected when the heel FSR sensor is OFF. T4 (heel off toe off): In general, toe off follows heel off. Heel off begins when the hallux FSR sensor is ON and front parts of the foot are OFF. T5 (toe off swing): In the toe off phase, the algorithm anticipates the transition to the swing phase. The condition for the transition to the swing phase is that all FSR sensors are OFF. T6 (heel off foot flat): If the subjects lifts the heel and then places it back onto the ground (without going into a swing phase, as in the normal walking), this event is detected in the gait phase detection algorithm by a transition from heel off to foot flat. If the status of the heel FSR sensor is ON during the heel off phase, the algorithm transits to foot flat phase.
TABLE I. Transitions in the gait cycle T1 T2 T3 T4 T5 T6 GAIT PHASE DETECTION ALGORITHM Sensors
Hallux Meta 1 Meta 5 Heel Petentio.

Figure 5. Flow chart of the control unit

SW HS FF HO TO HO

HS FF HO TO SW FF

OFF ON ON ON OFF ON

OFF ON ON OFF OFF ON

OFF ON ON OFF OFF ON

ON ON OFF OFF OFF ON

+ 0 - N/A N/A 0

2) Actuator Control Algorithm B. Control Algorithm 1) Gait Phase Detection Algorithm As shown in Fig. 6, a whole gait cycle is divided by five different gait events: HS (heel strike), FF (foot flat), HO (heel off), TO (toe off), SW (swing) [12]. Totally, six transition events were defined in both normal and pathological gaits. Gait events were determined by FSR sensors and a rotary potentiometer. Fig. 7 shows the actuator control algorithm of AAFO. D1 is in the loading response, the actuator make the plantarflexion by making shorter the length of SEA. D2 is from mid-stance to terminal stance phase, the actuator make the dorsiflexion by making longer the length of SEA. D3 is in the pre-swing phase which is requested the largest and rapidest plantarflexion, so the actuator make shorter the length of SEA most rapidly. D4 is in the swing phase, the actuator make the enough dorsiflexion to prevent dragging toe until the next heel contact.

Figure 6. Flow chart for the gait phase detection

Figure 7. Actuator control algorithm

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C. System Evaluation 1) Gait Phase Detection Algorithm The dynamic torque at the ankle joint of the orthosis was measured using the torque converter (YDN-10KC, SETech Company, Korea). Measurements were repeated three times, varying the PWM by 0%, 25%, 50%, 75% and 100% and then taken averages (Table 2). For the maximum PWM(100%), the maximum torque was turned out to be 97.2Nm, which was larger than 90Nm [13] based on the ankle plantarflexion moment of the normal subject (60kg).
TABLE II. % of PWM 0 25 50 75 100 DYNAMIC TORQUES OF THE ACTUATOR Dynamic torque (Nm) 0 24.7 1.3 48.8 0.9 75.8 0.9 97.2 0.9 Ankle joint angle () Motor rotation (number)

TABLE III. Max. ROM 33.41.4 28

THE ROM OF AAFO Max. Plantarflexion 21.51.4 18 Max. Dorsiflexion 11.91.0 10

3D gait analyses were performed on five healthy subjects (age: 27.52.1 years, height: 169.44.3cm, weight: 66.42.3kg) using a near-infrared 3D motion analysis system (Vicon 612, VICON, U.S.A.). Three different gait conditions were compared: the normal gait without AFO, the SAFO gait with the conventional plastic AFO, the AAFO gait with the developed AFO (Fig. 8). Totally sixteen reflective markers of 16mm diameter were attached to the positions based on the plug-in gait marker set [14]. Experiments were performed, after each subject was comfortable and familiar with each gait condition. For each condition, five repetitive measurements were made and then taken averages.

B. Ankle joint movement Fig. 9 shows ankle dorsiflexion/plantarflexion angles in three gait conditions. In the normal walking, the ankle joint was usually within a few degrees from the neutral position in the sagittal plane during initial contact. After initial contact, the ankle dorsiflexed about 7 during loading response phase and then plantarflexed about 17 during midstance and terminal stance phase. In pre-swing phase, the rapid plantarflexion of about 23 occurred to push off the ground and to progress the gait and then the rapid dorsiflexion about 15 occurred to return the foot to the neutral position until the toe clear from ground. However in the SAFO gait, the total ROM was about 10, which is very small compared with the normal gait. In addition, a rapid dorsiflexion for the shock absorption during loading response and the rapid plantarflexion for push-off were not found.

Figure 9. Ankle joint dorsi/plantarflexion angle

(a) SAFO gait

(b) AAFO gait

Figure 8. Gait analyses: Normal, SAFO and AAFO

III.

RESUTLTS & DISCUSSION

A. The range of motion (ROM) of AAFO Table 3 shows the ROM of AAFO. The maximum plantarflexion is about 21.5 by the shortest length of SEA due to 18 counter-clockwise rotations of motor at the neutral position. The maximum dorsiflexion is about 11.9 by the longest length of SEA due to 10 clockwise rotations of motor at the neutral position. The whole ROM of AAFO is about 33.4 so that the AAFO can control ankle joint ROM adequately compared with the normal walking.

Fig. 10 shows ankle dorsiflexion/plantarflexion moment in three gait conditions. In the normal gait, the plantarflexion moment increased from mid-stance to terminal stance and the maximum plantarflexion moment of about 1.5Nm/kg occurred in pre-swing. In the SAFO gait, a small dorsiflexion moment was found in loading response and the plantarflexion moment increased. The maximum plantarflexion moment in pre-swing was 1.1Nm/kg, which is about 65% of the normal gait. In the AAFO gait, the plantarflexion moment increased from midstance to terminal stance, and then the maximum plantarflexion moment of about 20Nm/kg was found in pre-swing. The maximum plantarflexion moment in AAFO was about 118% compared with the normal gait, which shows the proper pushoff.

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Figure 10. Ankle joint plantarflexion moment

Figure 12. Pelvic obliquity angle

Fig. 11 shows the ankle power in three gait conditions. In the normal gait, the maximum power was about 1.7W/kg during pre-swing. The maximum power of AAFO gait, about 1W/kg, was almost 2.5 times SAFO gait (about 0.4W/kg). These results showed that the developed AAFO could preeminently induce the normal gait compared with SAFO. Additionally, AAFO can prevent the foot drop by proper plantarflexion during loading response and provide enough plantarflexion moment as driving force to walk forward by the sufficient push-off during pre-swing. AAFO also can prevent the toe drag by proper dorsiflexion during swing phase.

the AAFO gait showed very similar obliquity movement to the normal gait, even though small upward obliquity angles were found compared with the normal gait. Fig. 13 shows the pelvic rotation angle in three gait conditions. In the SAFO gait, the large external rotation occurred during terminal stance and during swing phase compared with the normal gait. On the contrary, the AAFO gait showed almost the same rotations as the normal gait, even though small internal rotations occurred during loading response and small external rotations occurred during preswing. These results mean that the SAFO can bring a very inefficient gait by the abnormal pelvic movement with a compensation for the limited movement of ankle joint. On the other hand, the AAFO can induce an efficient gait with the similar movement as in the normal gait.

C. Pelvic movement Minimizing the displacements of the bodys center of gravity from the line of progression by the pelvic movement is an important mechanism to reduce the muscular effort of the gait and, consequently, energy saving [15]. Fig. 12 shows the pelvic obliquity angle in three gait conditions. In the SAFO gait, the upward obliquity angle rapidly increased, compared with the normal gait in pre-swing and early swing phase, then the hip-hiking occurred. However,

IV. CONCLUSION In this study an active ankle-foot orthosis (AAFO) was developed to provide proper ankle moment to prevent foot drop and toe drag based on an accurate detection of the gait phase.

Figure 11. Ankle joint power Figure 13. Pelvic rotation angle

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Then, we compared the conventional plastic AFO (SAFO) with the developed AAFO in healthy male volunteers using the 3D motion analysis system. The developed AAFO could preeminently induce the normal gait compared with SAFO. Additionally, AAFO can prevent the foot drop by proper plantarflexion during loading response and provide enough plantarflexion moment as driving force to walk forward by the sufficient push-off during preswing. AAFO also can prevent the toe drag by proper dorsiflexion during swing phase. In addition, SAFO can bring a very inefficient gait by the abnormal pelvic movement with a compensation for the limited movement of ankle joint. On the other hand, the AAFO can induce an efficient gait with the similar movement as in the normal gait. The developed AAFO could be useful in polio patients or patients with other orthotic devices.

Gyrosensor, Journal of the Korean Society of Precision Engineering, vol. 21, no. 10, pp. 196-203, 2004. [13] D. A. Winter, Biomechanics and Motor Control of Human Movement, Wiley-Interscience Publication, 2nd Ed., pp. 90-93, 1990. [14] R. B. Davis, D. Tyburski, and J. R. Gage, A Gait Analysis Data Collection and Reduction Technique, Human Movement, vol. 10, pp. 575-587, 1991. [15] J. Perry, Gait Analysis: Normal and Pathological Function, SLACK, pp. 38-47, 1994

ACKNOWLEDGMENT This study was supported by a grant of the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea. (02-PJ3-PG6-EV03-0004) REFERENCES
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