SCIENTIFIC PAPER

KNEE ANKLE FOOT ORTHOSIS COURSE

“Evaluation about Stance Control Knee Ankle Foot Orthosis

(SCKAFOs) Compared With Knee Joint Locking and Sensory Locking
Knee Joint for Quadriceps Weakness Patients”

GROUP 1:
Kencana Ningrum (P17127018010)
Rafidah Putri Yasminita (P17127018012)
Shabrina Illiyin (P17127018018)

Polytechnic of Health Science Jakarta I

Ministry of Health of Republic of Indonesia
2020
Evaluation about Stance Control Knee Ankle Foot Orthosis (SCKAFOs) Compared
With Knee Joint Locking and Sensory Locking Knee Joint for Quadriceps Weakness
Patients
Abstract:
Background: There are many kind of Knee Ankle Foot Orthosis especially component
each segment such as Conventional KAFO that use bar with usual drop lock knee axis and
the others type. KAFO usually required for patient who has quadriceps or knee extensors
weakness. To know which type of joint that better to use for quadriceps weakness so we
needed review and observation from the patient it self.
Objectives: The purpose of this review is to compare which type of knee joint more
effective for quadriceps weakness patient is Stance Control Knee Ankle Foot Orthosis or
Droplock Knee Ankle Foot Orthosis.
Study design: Literature Review
Methods: using research from Google scholar as knowledge database. Then find the article
review about that comparing the knee joint on SCKAFO and Knee Ankle Foot Orthosis
that used in patient with quadriceps weakness.
Result: The result of this study showed if Stance Control Knee Ankle Foot Orthosis can
improve ambulation patient with quadriceps weakness compare to Droplock knee joint
Conclusion: the data show that Stance Control Knee Ankle Foot Orthosis can be use to
quadriceps weakness patient because it help joint of patient during walking like walking
velocity, energy efficiency but reduced at walking speed also has small chance to do
compensatory gait for walking.
Article 1:
The Gait and Energy Efficiency of Stance Control Knee–Ankle–Foot–Orthoses: A
Literature Review
By Masoud Rafiaei, Mahmood Bahramizadeh, Mokhtar Arazpour, Mohammad Samadian,
Stephen W Hutchins, Farzam Farahmand and Mohammad A Mardani.
Article 2:
The Effect of 'SensorLock', a Knee–Ankle–Foot–Orthosis With an Electromechanical
Stance Control Knee Joint, on Walking Parameters and Gait Symmetry of Subjects
With Quadriceps Weakness: A Pilot Study
By Farnoosh Asadi, Mokhtar Arazpour, Monireh Ahmadi Bani, Gholamreza Aminian and
Reza Vahab Kashani.

Page | 2
Chapter 1
Background
Knee Ankle Foot Orthosis (KAFOs) is lower extremity devices which is extended until the
knee, ankle, and foot and prescribed for people with lower limb muscle weakness likes
weakness of quadriceps muscles. The example patient get weakness of quadriceps muscle
including poliomyelitis, post-polio syndrome, cerebrovascular accident (CVA), cerebral
palsy (CP), spinal cord injury (SCI), and multiple sclerosis (MS). The aim KAFOs is to
provide stability of the lower limb during locomotion. If the weakness of quadriceps
muscle, make it abnormality gait during gait pattern, and this condition may result in
decreased stability during activity.
Stance control KAFOs (SCKAFOs) are a new generation of KAFO which have been
developed to prevent knee flexion during stance phase and permit free knee motion during
phase of gait and usually activated by ankle ROM. The UTX, stance control orthosis
(SCO) knee joint, swing phase lock (SPL), Horton, Otto Bock Free Walk, and the Otto
Bock Sensor Walk are all examples of SCKAFOs. Using a SCKAFO produces an increased
acceptance rate for wearing orthosis by patients have weakness quadriceps muscles
because ability to control knee flexion in stance and free knee flexion during swing phase
of gait.
Studies have shown that over 40% of KAFO users are dissatisfied with their orthoses and
eventually between 58 and 79% of KAFO users stop using their orthoses and return to
wheelchair. More over chronic use of wheelchair can cause problems such as neuropathy,
painful shoulder, contracture in hip and knee, carpal tunnel syndrome and osteoarthritis.
SCKAFOs are clinically and commercially suitable. Although improvements in ambulation
and walking ability with SCKAFOs, compared to fixed-knee KAFOs, were reported in
previous studies, some SC knee joints designs are bulky and heavy.
Studies shown SC knee joint has been developed in the University of Social Welfare and
Rehabilitation Sciences called the 'sensor lock.' This design is similar to the Horton device,
but with a 'magnetic switch' that engages and disengages a pawl section.
Studies shown SCKAFOs improve gait by encouraging more normal gait patterns,
improving mobility, reducing the energy cost of walking, and reducing compensatory
strategies that may lead to chronic pain and loss of motion. But if we looked on
commercial SCKAFOs are often noisy, bulky, heavy, and expensive and in some cases are
not effective in improving kinematic variables and energy expenditure. Bernhardt et al.1
reported that it was slightly more difficult to sit down and stand up with the new SCKAFO.
Therefore, the aim of this scientific papers was to summarize the research on evaluation
the effectiveness joint knee for patient quadriceps weakness and for pilot study the aim to
evaluate an electromechanical SC knee joint -'sensorlock' it can solve problems related to
walking in patients with quadriceps muscle.

Page | 3
Chapter 2
kMethods and Material
Using the google schollar as our guidline, at the end we found 2 article to compare with the
inclusion criteria :

 The article was written not more than 5 years

 The article was written in english
 Using knee joint stance control to compared
 The subject patient is that having quadriceps groups
 Alanlyzed the gait of both groups that compared

Chapter 3
Result and Discussions
At first article, the study using collected data from 2 articles that evaluate about Stance
Control Knee Joint compared with Locking Knee Joint at Quadriceps weakness patient.
The authors collected data from internationally published scholary articles in Google
Scholar, PubMed, Science Direct, and ISI Webn of knowledge from years 1960 to 2013
with specific keyeword. From total 61 aticles that found, only 18 articles that accepted to
fullfill the criteria:
1. Studies which were considered for inclusion were randomized controlled trials
(RCTs), case–control trials, cohort studies, case series studies, and single-case
studies.
2. The article was written in English.
3. The study evaluated motorized (powered) or mechanical SCO using over training
time in poliomyelitis subjects.
4. The study investigated individuals with a lower limb weakness (poliomyelitis, post-
polio, and SCI) and able-bodied subjects.
5. The main outcome measures of the article were balance, gait, energy consumption,
kinetics, kinematics, and tempo-spatial parameters.

Page | 4
Then second article, the authors do the test to 6 patients with BMI (20.7-29.71kgm − 2),
weight 56–82kg, Age 46.71±6.29years, Agerange 37–53years.

The inclusion criteria are:

1. Patients routinely used KAFO unilateral with loackable orthotic knee joint.
2. Having ability to walk minimum around 50m.
3. Sufficient hip flexor strength (minimum having muscle stength on level 3 of the
Oxford Scale) to advanced the limb during swing phase.
The exclusion of this study are:
1. The existance of impaired cognition, poor balance.
2. Has soft tissue contractures greater than 15˚at the hip, 10˚at knee, and 5˚at the
ankle.
3. Othostastic hypotension, Cardiac Arrhythmias, Vestibular Dysfunction and
Peripheral Neurophaty which has risk to falling, having near fall or loss of balance.
Intervention. According to study, the device that participant use custom made by
experienced orthotist, made molded thight cuff and solid ankle orthosis. The exact location
of knee and ankle joints, longitudinal distance between the knee and ankle joints, diameter
of ankle and knee joints, medial longitudinal distance between perineum to the knee joint
associated with precision casting of the lower limbs were considered as important
parameters in the construction of KAFO for each patient.
Stance Control Knee Joint. A new design consist of a foot switch with rubber bed under
the heel, a magnetic switch, and 1 way lock mechanism that has 6teeth pawl. The ‘sensor
lock’ mechanism work locking in stance phase and free knee motion in swing phase.
Control of SC Knee Joint. When stance phase, the spring force push the pawl up against
gravity to maintain lock in extension and stable then when swing phase, the heel sensor
offload and the magnetic active to allow flexion of knee for swing.
Battery. Has rechargeable 24V battery. If the battery low or removed from the place, this
SCKAFO mechanism back to droplock KAFO.

Page | 5
Gait training with SCKAFO. All of the objective was perfomed in rehabilitation center
under the supervisor. The orthotic gait training was performed on the level ground 2 hour
per day, 3 day per week and for 2 week and its program included five phases.
Phase 1 was performed in the pre-orthosis wearing to increase strength of the pelvic and
abdominal muscles to provide perception of pelvic rotation and retroversion.
Phase 2 was to permit the KAFO user to get self dependence via standing and weight
bearing with the SCKAFO with the locked knee joint position within the parallel bars.
Phase 3 composed walking in the SCKAFO with emphasis on the stance phase the goal is
to perform locking and unlocking of the stance control knee joint during walking. Locking
of the stance control knee joint in the stance phase from initial contact to terminal stance
was important in this stage to provide stability. In addition, equality of the step length in
this phase educated during training.
Phase 4 was walking with SCKAFO with emphasis on the swing phase. Unlocking of the
stance control knee joint at terminal stance and generation of the extensor momentum to
provide extension of the knee joint before next step were trained in this stage. Walking
with SCKAFO outside the parallel bars was considered as the final stage of the orthotic on
the gait training.
Data Collection. A camera frequency 100Hz used to capturing subject motion during
walking with the orthosis. The data will analyzed using MATLAB (Math Works, Natick,
MA, USA).

For the first article, about energy efficiency when using SCKAFO. Only 3 studies
evaluated about energy comsumption in normal subject, subject with lower limb
pathology, and subject with post poliomyelitis. And there are 2 studies evaluated that
SCKAFO create 0.447beats/min than droplock KAFO create 0.554 beats/min in energy efficiency
means SCKAFO more safe energy.
And about kinematic efficiency of SCKAFO there are some point to compare like Speed
of Walking. In normal person got 1.3m/s of walking speed but by using SCKAFO the
speed only 0.57m/s means has been reduced. 3study demonstrated increased walking speed
but there are 5study demonstrated reduce walking speed using SCKAFO if compare with
droplock KAFO.
Walking Velocity improved using SCKAFO that attach at RGO in SCI patient.
Cadence. 6study said increase cadence during walking using SCKAFO compare to
droplockKAFO but has a study find reduction in cadence when using SCKAFO.
Step Length. 3study said step length reduced when using SCKAFO compare than locked
KAFO. 1study reported that got similar result step length between SCKAFO and locked
KAFO.

Page | 6
Knee ROM. Healthy person need 67˚flexion during swing phase but using SCKAFO, the
healthy person can do flexion mean at 40˚flexion. And for patient got quadriceps weakness
can reach 50˚flexion in swing phase.
Pelvic obliquity. Evaluated 6 SC user in 6months and result is all subject had significantly
lower pelvic obliquity, 2.8 mm (p = 0.04). The SCKAFO improved pelvic obliquity and
provided a more natural gait for the users.
Vertical and lateral displacement. The result reduction vertical and lateral displacement
using SCKAFO than droplock KAFO in quadriceps weakness patient.
From all the demonstreated can take some contraindication of using SCKAFO like
impaired cognition, knee flexion contracture >10°, moderate to severe spasticity of the
hamstrings, lack of hip abductors in bilateral patients, uncorrectable genu varum/valgum
>10°, lack of motivation or inappropriate expectations, and body weight >300 lbs.
And for the droplock KAFO makes the patient do some like KAFO users are forced to
walk with the knee in a locked position, hip hiking strategy, leg circumduction, or a
vaulting gait and can caused soft 7tissue injury, an increased effort to walk, and a high rate
of energy consumption in KAFO users.
For the second article, using Temporal-spatial parameter reported the walking velocity was
reduced in the stance control compared to locked knee mode position (SC mode 0.31m/s
and locked in full knee extension 0.32 m/s). In the affected side walking with KAFO in the
SC mode also provided a longer stride length compared to walking with KAFO in the
locked knee mode (SC mode 0.68m and locked in full knee extension mode 0.65m).
(stride length)
Cadence. Reduced in the SC mode compared to the locked knee mode. The authors said
there were no significant differences between KAFOs with two types of knee joints in this
study with regard to temporal–spatial parameters. For the kinematics , maximum knee
flexion angle during swing phase increased when walking with SC mode compared to
walking with the KAFO in knee joint lock mode (SC mode 25º, locked mode 4º).
Maximum of hip joint flexion increased and maximum hip extension decreased when
walking with SC mode compared to walking with the KAFO in knee joint lock mode, it
has significant differences.
using Gait Symmetry Index. There is no significant differences in the symmetry index of
step length or speed of walking between walking with KAFO with SC mode and locked
knee joint mode. A different speed was calculated for each leg. Using KAFO with SC
mode knee joint significantly decreased the gait symmetry index when applied to knee
flexion during swing phase compared to walking with KAFO with dropped locked knee
joint.
eh rekomendasi kita gini ga " becasue the gait training time in skafo is
different from usual kafo, so the walking speed having no significant increase after
the gait training. We suggest to future research can provide better benefit for the
research. And then also we only compare from 2 article

Page | 7
Aim of the study is to compare the effectiveness of stance control knee joint with the
locked knee joint at conventional KAFO’s. Also, from two types it has different
reccomended indication. Subjects with lower limb weakness can use a KAFO with drop
locked knee joints and users who have sufficient hip strength can has benefit from a
SCKAFO, and the criterion for using a SCKAFO is the presence of hip strength of at least
Grade 3.
The proved of reduced energy consumption has been quoted as one of the main aims and
reasons for subjects with lower limb weakness to walk with a SCO. Due to paralysis of the
lower limb muscles, KAFO users are forced to walk with the knee in a locked position, hip
hiking strategy, leg circumduction, or a vaulting gait, this can cause soft tissue injury, an
increased effort to walk, and a high rate of energy consumption in KAFO users. From two
articles , one articles founds only three studies evaluated the parameter in poliomyeletis
suvjects wear SCO compared of locked KAFO, besides the advantages of walking with a
SCO, this type of orthosis has not demonstrated a significant improvement by producing
decreased energy consumption, but it will increase knee joint flexion and extension during
swing because the SCO provides locked knee in stance phase and provides free flexion
during swing phase ambulation.
Using a powered SCO may provide this, but the slow walking speed provided by these
orthosis. Experience of users during walking with the SCO must be increased over time to
provide more ability in controlling the orthosis. The concentration that need for SCKAFO
control may be the cause of the shorter stride lengths demonstrated, associated with longer
stride times, and therefore slower walking speeds. From second artcles , participants were
experienced KAFO users who used orthosis with locked knee position it may have more
difficult to use the new system. In other studies, increased speed and cadence were
reported in using the automatic mode in a SCKAFO compared to wearing the locked mode
KAFO, but the other reports showed, no change between the locked and auto modes in
terms of temporospatial parameters.
Longer times of accommodation with the orthosis and more experience in using KAFO
with stance control knee joint is therefore required to enable subjects to produce faster
walking speeds when walking with this type of orthosis , but subjects with poliomyelitis
had slower speed of walking, decreased cadence, prolonged stance duration, and shorter
step lengths. The SI of step length increased. The SI of the knee flexion and speed of
walking decreased when the KAFO with stance control was used compared to KAFO with
lock knee joint mode. Based on the improvement of the swing phase flexion illustrated
with the stance control knee joint in wearing KAFO, improvement of gait symmetry during
swing may be expected. Howeever , from two articles that we compared , gait training
should be performed for several dyas or weeks to bceome more experienced in walking in
order to increase ability and confidence of users to control the stance control knee and to
improve the gait function before being compare to other device. One of the articles claimed

Page | 8
if their limitation is because of the short time of the grait training. So for the further studies
that can resolve the limitations is more beneficial.

Chapter 4
Conclusions
From article 1, SCKAFO shown to support the knee joint during stance phase and provide
free knee movement during swing phase successfully in all the walking studies. SCKAFO
designs have provided improved gait kinematics for KAFO users and provide
improvement in pelvic obliquity and vertical and lateral displacement during walking. But
disadvantages of this new type is not efficient in decreasing energy consumption during
walking.
From article 2, The KAFO with SC mode provided knee flexion in swing phase and can
associated with stability in stance, compared with KAFO swith locked knee joints mode,
using demonstrated a slower speed of walking and increased peak knee flexion in graph
during swing in this study. The SI of the knee flexion and speed of walking decreased
when the KAFO with stance control and the improvement of the swing phase flexion
illustrated with the Stance Control KAFO, improvement of gait symmetry during swing
may be expected.
Generally, the new type knee joint its Stance Control KAFO result good outcome for
patient who has quadriceps weakness in term of walking velocity, walking speed, knee
ROM and the smoothness gait during walking if we compare to Droplock or traditional
KAFO but disadvantages of this new type is much consume energy to control in stance and
because of the short time of the grait training. So for the further studies that can resolve the
limitations is more beneficial.

Page | 9
 REFERENCES

Masoud Rafiaei1, Mahmood Bahramizadeh, Mokhtar Arazpour, Mohammad Samadian,

Stephen W Hutchins, Farzam Farahmand and Mohammad A Mardani1. “The Gait and
Energy Efficiency of Stance Control Knee–Ankle–Foot Orthoses: A Literature Review”,
sagepub.co.uk/journalsPermissions.nav 2015

Farnoosh Asadi, Mokhtar Arazpour, Monireh Ahmadi Bani, Gholamreza Aminian and
Reza Vahab Kashani. “The effect of 'Sensor Lock', a knee–ankle–foot orthosis with an
electromechanical stance control knee joint, on walking parameters and gait symmetry of
subjects with quadriceps weakness: a pilot study”, scsandc.2017.35

Page | 10