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Produce inhibitory/excitatory inputs to

higher centres of the brain. No output to
spinal cord.
Caudate and Putamen = Striatum
Globus Pallidus Internus (GPi) and Externus
Subthalamic Nucleus (STN)
Substantia Nigra Pars Compacta (SNc) and
Pars Reticulata (SNr)

DIRECT PATHWAY (D1+ excitatory) CoSST

Basal ganglia initiates voluntary movement
by disinhibiting thalamic neurons
Cortex(stimulates) Striatum(inhibits)
"SNr-GPi" complex(less inhibition of
thalamus) Thalamus(stimulates)
Cortex(stimulates) Muscles, etc.
(hyperkinetic state)
INDIRECT PATHWAY (D2- inhibitory)
Responsible for termination of movement.
Inhibits unwanted movement by increase in
excitatory input to Gpi + SNr.
Cortex(stimulates) Striatum(inhibits)
GPe(less inhibition of STN)
STN(stimulates) "SNr-GPi"
complex(inhibits) Thalamus(is
stimulating less) Cortex(is stimulating
less) Muscles, etc. (hypokinetic state)
Basal ganglia disorders
Too much basal ganglia output, the
thalamocortical projections become
inhibited + cant initiate voluntary
movement = hypokinetic.

Abnormally low basal ganglia output, leads

to no inhibition of thalamocortical projections
unable to supress unwanted movements =
Movement: Parkinson; Huntington; Tardive
Dyskinesia; Dystonia; Hemiballismus.
Non-movement: Tourette; OCD
Symptoms: T.R.A.P (tremor, rigidity, akinesia,
Loss dopa: 1) Oxdn stress; 2) apoptosis; 3)
Detrimental changes mDNA. Symptoms =
80% neuron death
Habituate to meds, develop levodopa
induces motor dyskinesia and dystonia
Deep Brain Stimulation (DBS)
Platinum iridium electrodes implanted in
Inclusion: L-dopa sensible; can operate
device; no cognitive impairment, no
psychiatric illness, no pacemaker. (10-15%
PD pts eligible) DOC-PP
DBS in either STN or GPi improves postural

Less economical burden, DBS decreases by

half dopa use
Neuropatologies DBS
Parkinson: STN, GPi, PPN
Essential tremor: VIN of thalamus
Dystonia: Gpi
Epilepsy: Depend on foci of involvement
Depression: Subgenual Cingulate; Nucleus
OCD: STN, Anterior Internal Capsule
Chronic pain: Hypothalamus (cluster
Mech of DBS
High freq stimuli (100-150 Hz)
Inhibit activity of neurons + output of nucleus
Parameters DBS in PD
little difference in the motor improvement
with either placement site of the electrodes
Stimulation amplitudes and pulse widths
were lower for subthalamic stimulation than
for pallidal stimulation, allowing for longer
intervals between pulse-generator
replacement among patients undergoing

Neuropsychological Effect
Detrimental effect by STN-DBS in apathy
and depression
Quality of Life
STN-DBS decreased communication
Increased mobility
Better patient preparation (unrealistic
Sacral plexus (L4-S4)
Obturator and Femoral nerves (L2-L4)
Sciatic nerve (L5-S3) -> Common peroneal
+ Tibial
Femoral Nerve (L1-L4)
Gluteal grp: maximus; medius; minimus;
tensor fasciae latae
Lateral rotator grp: Obturator; piriformis;
gemelles; quadratus femoris
Adductor grp: longus; magnus; brevis;
pectineus; gracilis
Iliopsoas grp: iliacus; psoas.
Flexors knee: Biceps femoris;

Extensors Knee: Rectus femoris; vastus

lateralis, vastus intermideus, vastus
Flexors ankle: Tibialis anterior
Extensors ankle: Gastronemius, soleus,
plantaris, tibialis posterior, peroneus
brevis, peroneus longus
Flexor toes: digitorum longus, halluces
Extensor toes: digitorum longus, halluces
Centre of Mass (CofM): mass concentrated
unaffected by external linear forces
Base of Support (BofS): area between feet
Stance is dependant of ability to maintain
CoM within Base of support
Stability: ability to maintain equilibrium
after displacement
Mechanical principles human stability

Centre of Pressure (CofP): point of

application of the ground reaction force vector
(-[weight + inertia])
An increase in sway is not necessarily an
indicator of poorer balance, indicates
decreased neuromuscular control,
postural sway is a precursor to a fall
Mechanical Model Quiet Stance
Inverted pendulum model: the difference
b/w CofP and CofM is proportional to the
horizontal acceleration of the CofM
Two models: 1. Frontback; 2. Lateral:
CofM in front ankle, torque is created
opposed by CofP creating counter torque.
CofP-CofM = -I*x/W*d = -Kx
Afferent systems involved (3): Visual,
Vestibular, Proprioceptive
Neural control Balance
Medial system (Reticulo + Vestibulo)
1. Reticulospinal pathway-> Medial (pons
tone) + lateral (medulla - movement)
Decerebrate rigidity: removes inhibitory
descending drive to reticular formation (NA +
2. Vestibulospinal pathway -> 2 otoliths

Types reflex
1. Vestibulocervical reflex: Stabilize head on
body with Medial vestibulospinal pathway.
Head rotates/tilts in one direction, contract
neck muscles to oppose motion (2-3 Hz
2. Vestibulospinal reflex: Stabilize body with
Lateral vestibulospinal pathway. Body
rotates/tilts in one direction, contract ipsilateral
extensor muscle to counteract.
Strategies Postural Control (4) IESA
1. Interaction of the 3 Sensory systems
2. Environmental conditions
3. Sensorimotor strategies: interaction b/w
motor and sensory systems
4. Attentional strategies
a) Ankle strategy:
1. Ford sway = Para, Ham, Gast
2. Back sway = Abd, Quad, Tib Ant.
b) Hip strategy:
3. Ford sway = Abd, Quad
4. Back sway = Para, Ham
Loss of sensory system affect postural strategy
. Vestibular loss -> ankle stategy

Major functions of Gait (SPFEgA)

1. Support upper body during stance
2. Total body upright posture and balance
3. Foot trajectory control: safe ground
clearance gentle heel/toe landing
4. Mechanical energy generation:
maintain/increase forward velocity
5. Mechanical energy absorption: decrease
velocity, shock absorption and stability
Biomech measures walking (temporal +
. Cadence: #steps/time (avg 101-122)
. Stride length: distance initial contact foot
to next initial contact of same foot (avg
. Velocity = length*cadence/120
Phases of Step Cycle
. Stance phase: ~60%. Foot is on the
ground. Early (foot contact), mid, and late
stance (push off).
. Swing phase: ~40% time. Foot is in the
air. Early and late swing

Vertical displacement of CofM during

CofM vertical movement 1.7cm men, and 1.2
cm Women.
Kinetic and potential energy trade-off
when ground distance changes
First half stance phase: kinetic energy
converted to gravitational potential energy
Second half stance phase: opposite
Vertical displacement CofM is directly out of
phase in the horizontal phase, allows major
conservation of energy
Ground reaction forces during walking
Vertical GRF force exceeds that needed to
support body weight
Early Swing: Mean joint angle
flexion/extension for joints leg: plantarflex
push-off (ankle), Flexion during weight
acceptance (knee), Flexion as leg is pulled
through swing (hip)
Plantar flexion: main propulsion force during
walking (gastrocnemius)
Late Swing: Mean joint angle/torque walking:
small dorsiflexor moment to lower foot to

Support moment = overall extensor

moment of the 3 leg joints. Ms =
Indicates limb pushing away from ground
Correlates with vertical ground reaction
force (r = 0.97)
Hip knee trade off offer redundancy
Trade off among the knee and hip joint
with movement.
Force plate (4 triaxial transducer vs
Ground reaction force is the most
common external force acting
Triaxial transducer: Calculate CofP by
determining relative vertical forces at
each transducer
Plate: calculate force where position x
on the plate
Floor reaction force vector: Incorrect
analysis method. Postulates joint moment
equal to the magnitude of the vector
multiplied by perpendicular distance

3 main errors:
1. Magnitude moment is incorrect
2. Polarity of the moments would be
3. Cant be used to calculate moments in
non-weight bearing times

Walking CofP, CofM trajectories

40% standing on each limb and 20%
double support.
CofM decelerating while behind stance
foot, and accelerating as it moves in
front of the stance foot.
Human body never more than 400 ms
away from falling
CofM never travels within base of
CofM while behind the foot, the
medial-lateral trajectory is toward the
stance foot. Once it passes to the front
trajectory moves to the swing foot

Power generation during walking cycle

Power is the product of the joint moment of
force and joint angular velocity (Pj = Mj * j).
Ankle: 5-40% step cycle, ankle undergoing
35-40% heel lifts off the floor, active and
Product of the moment and rotational
acceleration in same direction whereby a
large energy generation phase occurs
Ankle main power generator in walking
Muscle activation during walking
Swing phase: Dorsi flexor, peroneus, soleus,
Stance phase: plantar flexor, gluteus, vastus
Erector spinae: early stance and early swing
Abdominals activated low level step cycle
Biphasic pattern during walking
Hip extensor
Glut max 2 bursts: late swing->stance; early
Rectus femoris: (2 bursts) early stance, and

Gastrocnemius: early stance (up to 40%
step cycle).
Soleus: early stance; last third of stance
Tibialis ant: end swing/beginning stance;
Gastronemius stabilize ankle
Gastro lateral: help lower toe
Gastro medial: activated during propulsion
Tibialis anterior prevents foot drop and
gives toe clearance
Neural control Walking
1. Central Pattern Generators (CPG)
2. Afferent Input: regulate pattern and
3. Descending control from higher centres
. Cats could walked with full spinal
. Proposed half-centre: excitatory neurons
(flexor extensor) mutually inhibitory
through interneurons
. two-layer effect: rhythm and timing

1. Each limb controlled by separate CPG
2. Each CPG contain 2 excitatory grps that
control flexor and extensor motoneurons
3. Mutual inhibitory interconnections b/w halfcenters ensure only one center activated at
the time
4. fatigue: gradually reduces excitation in
active half-center
5. Phase switching: reduction in the excitability
of one half-center below critical value and
opposing center released from inhibition
6. Inhibition of antagonist motoneurons is tightly
coupled to excitation agonist
Unit Burst Generator: unilateral, multipartite,
shared and modular
7. Control an agonist at a single joint of a
8. Produce rhythmic bursts of output even when
the generator of its antagonist is quiescent
9. Shared: each UBG used in different behaviours
CPG (+2 levels)
. Rhythm generation and amount of
motorneurons recruited are executed by

Afferent Control of Locomotion theories

1. Muscle spindle (stretch): information
from hip flexors move leg from stance to
swing phase and contralateral limb into
2. Golgi tendon (force): information from
ankle extensors. Load (from golgi) prevent
the leg from moving into swing, while loss
of expected loading will cause leg to flex.
Stumbling corrective response
. Hitting object with foot during swing phase,
activates cutaneous receptors on dorsum
creating unexpected coordinated flexion
with contralateral extension to allow leg to
extend past the obstacle.
. Effects in tibial and sural nerve (latency
Higher centre role in walking
Brain Stem
. Mescencephalic Locomotor Region (MLR):
moderate activity in reticulospinal neurons
through cholinergic inputs
. Subthalamic locomotor region (SLR): causes
initiation in goal directed manner

Brain stem
Cochlear nucleus, cuneate nucleus, substatia
grisea centralis and spinocerebellar tract:
induce locomotion
Lateral hypothalamic area: walk slowly, head
extended, looking around
Damage causes ataxic gait: wide-base
Lack of modulation of firing in reticulospinal
Basal ganglia
Initiation of locomotor activity
Proper force generation development in
extensor muscles for postural adjustment
Modulation of gait cycle
Visual input to cortex permits planning of
foot landing while avoiding obstacles
Expected obstacle avoidance activates
pyramidal tract (corticospinal neuron)
Unanticipated gait perturbations activated
motor neuron graded to the size of

Main concern is a stable, sturdy limb.
JaipurKnee project
Components Above knee amputation
1. Socket: Suction suspension
2. Knee:
3. Shank: support
4. Foot-ankle
5. Support body during standing, walking
. Transtibial amputees expend 20% more
energy than those without
. O2 requirements increase at each higher
amputation level
Prosthetic Joints
. Passive in action. 60% more metabolic
. Rely upon ground force effects, sliding
joints, and mechanical components
. Control prosthesis come from extra
movements from hip and residual limb
. Vanderbilt: powered knee-ankle, load

The Foot
3c level: Control, Comfort and Cosmetics
Types: Conventional, Energy-storing-andrelease (ESR) and bionic
A. Conventional:
1. Solid Ankle Cushioned Heel (SACH)
. Most common and cheapest
. Solid ankle, rigid foot, cushioned heel
. Pediatric or geriatrics; when potential
functional level yet to be determined
2. Single axis foot:
. Bumpers control ankle flexion
. Little shock absorption or energy return
. Dynamic elastic response feet flex at heel
strike and midstance and spring back at late
. Reduces energy expenditure
. Seattle foot (1985): monolithic keel. Allow
energy storage, expenditure.
1. Carbon graphite foot:
. lightweight, integrated pylon.
. Moderately active below or above knee
. Excellent shock absorption, flexibility, energy

C. Bionic Feet (pneumatic, electric)

1. Pneumatic
Muscle-like pneumatic actuator: powered TT
prosthetic. 110 Nm, ankle 30 degree
Pleated Pneumatic Artificial Muscle (PPAMs):
TT prosthetic. Contraction or stretching axially,
pulling force on load. 200Nm and lightweight.
Transfemoral: Both knee and ankle pneumatically
2. Electric
SpARKy (Spring Ankle Regenerative Kinetics):
100% push-off, intact gait kinematics
MIT media lab powered ankle: Spring and Series
Elastic Actuator (SEA). Improves 14% metabolics.
Ankle stiffnes changes with phase of walking cycle
Proprio foot: function as ESR, but makes use
active components to adjust ankle angle
Controlled Energy Storing Release (CESR)
clutch mechanism
Recycle kinetic energy generated while walking
Average foot-ankle for 3 phases prior to push-off: absorbed in early stance; 2. work generated
in early stance; 3. work absorbed mid to late stance
Powered ankle foot prosthesis Neuromuscular
Hill- type muscle model and spring-damper to 2-link
ankle joint model

Knee joint classification

1. No mechanical knee control
2. Stance phase control (LAB-LR)
a. Manual locking knees
b. Alignment controlled knee units
c. Friction brakes that lock knee on
weight bearing
d. Polycentric linkages
e. Fluid resistive devices (hydraulic or
3. Swing phase control only
Swing control to maintain consistent gait.
a. Constant resistance: simple,
lightweight and dependable
b. Variable resistance: increased
resistance as the knee bends
c. Cadence responsive resistance:
variable walking speeds. Frequent
adjustments and replacement.
4. Stance and Swing phase control:
Allow both stance and swing to be controlled.
Ie C-leg
Sensors register position and load,
microprocessor determines state of the leg,
and dual mode activation for changing

Socket Technology
Patient-prosthetic interface. Can create sense of
instability and uncertainty in the control
Custom fitted: donning stocking net over residual
limb, identify anatomic landmarks, and casting
with plaster. Stump changes over time (atrophy)
Ie transtibial amputee: patellar tendon, tibial
condyles, are able to support higher loads
Problems Inappropriate fitting (PEVI)
a. Pressure sores
b. Edema
c. Vascularity Compromised
d. Infections
Dynamic loading during walking
Finite element (FE) analysis predicts excessive
loading in a user-socket interface

Body Weight support retraining (BWS)

Improves locomotor activity in spastic paretic
patients and severe SCI (initiated with 40% BW). 6
months end of training.
Improvement on speed, distance, static surface.
SCI generate locomotor oscillations, afferent input
helped modulate patterns
Generation appropriate locomotor pattern
depends on combo of central programming

Generation appropriate locomotor pattern

depends on combo of central programming
and afferent input that are context
Connections in the cord can be
strengthened with training
Relevant afferent involved in proper rhythm
deal with load from extensors (golgi) and from
hip flexor stretch (spindle)
In incomplete compromise, leg movement
have to be assisted during the first part of
training (as opposed to complete)
Incomplete EMG patterns similar to healthy
individuals but lower amplitude
Complete SCI no locomotion improvement,
however, there is improvement in both CV and
Locomotor training using robots. Ie: lokomat;
Driven gait orthosis (DGO): replace physical
therapist for leg moving (tiring + not proper
Might not be feasible due to price.

1. Gait training 2. Shift weight b/w feet 3.
Restore faith
Patient type: incomplete/complete SCI,
stroke TBI.
Design considerations (SAD JoPPP)
2. Power supply: battery
3. Actuators: servomotors
4. Skeletal components: titanium/ carbon
5. Joint flexibility
6. Power control and modulation
7. Detection of incorrect/unsafe
8. Pinching/joint fouling
. ReWALK: Powered hip-knee, fully
assistive. Mode sit, walk, stair.
. Exoskeleton Lower Extremity Gait
Systmem (eLEGS): 6hrs battery. Walk
Modes: First, Active, Pro, Pro Plus. Assist
Modes: Bilateral, Adaptive, Fixed.
. Hybrid Assistive Limb (HAL): 3hrs battery,
Japan. Cybernic Voluntary Control (CVC)

EKSO: person with lower extremity

weakness. Powered hip, knee, spring
ankle. Walk Modes: First, Active, Pro, Pro
Plus. Advantage: data wirelessly,
Disadvantage: heavy, secondary
INDEGO-Vanderbilt: restore legged
mobility in paraplegia and stroke. Can be
dismantled and functions in conjunction
with FES. Uses onboard embedded
microprocessors and sensors. Fxn:
walking, standing, sit-to-stand, stairs
Rehab Technology Standing Walking
FES for ambulation: WalkAide
Foot drop: tilt of accelerometer creates
stimulation peroneal nerve which
activates tibialis anterior muscle during
swing phase to prevent toe drag
Used in CVA, MS, SCI, TBI, Brain tumor,
and CP
BION microstimulator injectable out of

Walker with manual push-button controls

activates different programs (sit, stand,
6-channel surface electrode with
microprocessor and a battery.
Electrodes placed in quadriceps to
sustain knee, and on lateral peroneal
nerve for flexion withdrawal reflex
Connections within the brain can be
changed, and other areas of the brain
can take over some functions of
damaged areas
Substantial changes occur in the lowest
neocortical processing areas.
Changes can alter neuronal activation
patterns based in experience
anatomically and functionally
Sensory substitution
Tactile sensation on tongue to indicate
head tilt
Vibrotactile feedback from