JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
A REVIEW ON PROSTHETICS AND ORTHOTICS
FOR AMPUTEES AND DISABLED
Keerthana R1, Mary Clare Jochan1, Surya Dharshini M1, Suraj Susamma Sunilkumar2, Satya Kalidindi3
and Vidhya S1*
1
Department of Sensor and Biomedical Technology, Vellore Institute of Technology, Vellore-632014
2
Biomedical engineering, Faculty of Engineering Science, KU Leuven Belgium.
3
MS Bioengineering, Clemson University, South Carolina.
1
* Associate Professor, Department of Sensor and Biomedical Technology, Vellore Institute of Technology,
Vellore-632014
Contact detail: svidhyavalentina@[Link]
Received: 12 May 2020 Revised and Accepted: 09 July 2020
Abstract: This case study gives an overview of the prosthetics and orthotics used on patients for better gait
rehabilitation. Many people suffering from various muscular and neurological diseases, lower-limb amputees,
elderly are dependent on various prostheses and orthoses for a better quality of life. The review is considered under
three categories: above-knee prosthesis, below-knee prosthesis, and orthotics. Each group is divided into its
subdivisions with respect to the part of the body it is suspended. This paper reviews the currently available
prostheses and orthoses. An analysis of the various designs and materials for each device, as well as the discussion
of their limitation, are provided.
Key words: gait rehabilitation, lower-limb amputees, orthotic devices, prosthetic
I. INTRODUCTION
Prosthetics and Orthotics are mechatronics systems that are designed to replace a missing part of the body
structurally and functionally and to increase the physical abilities of amputees and disabled. In the past years,
transfemoral prostheses (above the knee prosthetics) have developed to microprocessor control systems from
simple mechanical systems. The trans-tibial prosthesis, also referred to as below the knee prosthetics are used to
provide gait rehabilitation after the below-knee amputation caused by several problems such as cancers, infections,
neuroma, or severe injury [1][2][3]. The prosthesis is usually suspended to the residual limb of the below-knee
amputees. The residual limb must be well-formed, round, and healed adequately at the end for the suspension of
the prosthesis. The significant advancement of prosthetics goes back to the time after the Second World War, when
a team at the University of California, including James Foort and C.W. Radcliff, developed a quadrilateral socket
by developing a jig fitting system. The usage of jigs helped in holding the residual limb in the right position,
making it fit in the socket, providing a convenient and comfortable walk to the amputees. Considering the
complications involved in the usage of jigs in prosthetic limbs, there have been advancements under it involving
plastic materials like carbon fiber. With the increase in technology and extensive usage of Artificial Intelligence,
specific electrical circuits are included in the prosthetic limb, allowing them to operate similar to a fully functional
human leg. Myoelectric limbs are one of these advancements which control the limbs by converting the muscle
movement into electric signals, indeed inducing smoother usage. This paper gives a review of the literature on the
below-knee prosthesis that are currently in use.
Orthotic devices have been developed to assist people suffering from various muscular or neurological diseases.
It is also extensively used for stroke survivors and older people in gait rehabilitation. Each gait cycle has two
phases – the stance phase and the swing phase. The stance phase of walking is composed of a weight acceptance
phase (~ 40%) and stance termination phase (~40-60%). The knee exhibits an enormous moment and considerable
flexion in the weight acceptance phase [2]. The primary objective of these orthotic devices is to support the knee
during weight acceptance phase and to provide free movement during the swing phase. Various methods offer a
2175
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
locking and unlocking system that locks the knee in an extended position, which keeps the individual throughout
the stance [4]. Within this paper, we discuss the different orthotic devices and their mechanisms which support
the needy people.
II. EXPECTATIONS OF PROSTHETIC AND ORTHOTIC DEVICES
A. User-friendly
Prosthetic and orthotic devices play a significant role in gait rehabilitation. Although many factors affect gait
rehabilitation such as physical therapy, surgical care, psychological support, the quality of the prosthetic or
orthotic devices is mainly concerned. People prefer more comfortable and user-friendly devices. Such devices
must be capable of withstanding the load and must support the user with his daily activities while providing
comfort and safety. The function of these devices varies depending on the user and the terrain. These devices must
quickly adapt to user requirements. Thus, a proper understanding of the physical and functional needs of the user
has to be studied. The prosthetic and orthotic devices must ensure comfort and maximum mobility for their
excellent performance.
B. Adaptability and robustness
The prosthetic and orthotic devices must be preferable over all terrain. Some of the devices are not suitable for
some terrains. It must be able to operate across all terrain and should be able to withstand varying weather
conditions. The devices must be more compact and less bulky, which makes it more adaptable. Robustness refers
to the state where it can function under typical conditions and for an extended period.
C. Durability
Durability is one crucial factor that every user considers. Users are often unsatisfied with less durable products.
Maintenance is another essential factor. The more routine the device is maintained, the more it lasts. So the
prostheses and orthoses must be simple and easy to repair, requiring minimal parts for repair. Moreover, the device
must be easy to clean and maintain.
D. Affordable
Cost plays a crucial role in the decision process of whether to wear a prosthetic or an orthotic device. An
amputees’ inability to afford the prostheses can significantly affect his quality of lifestyle. A lot of older people
who depend on gait rehabilitation can have a better quality of life if these prostheses are affordable. These must
be cost-effective not only during the purchase but also for the maintenance. Thus, the availability of these devices
in a more accessible manner can have a better impact on the user lifestyle.
III. CURRENT PROSTHETIC AND ORTHOTIC DEVICES
Prosthetics and orthotic devices have a significant role in gait rehabilitation. An extensive literature study was
conducted with over one hundred articles, patents, and research papers on various prosthetic and orthotic devices
for the lower limb. These were then classified as upper knee prosthetics, lower knee prosthetics and knee orthotics.
Some of the prosthetics developed in the recent years are shown in Table-1.
Table-1. Prosthesis developed in recent years
Ref
Year Name of the Prosthesis Type
2006 Bionic ankle-foot prosthesis Below knee [5]
2008 Agonist–antagonist active knee prosthesis Above knee [6]
2008 Waterloo Active Prosthetic Knee Above knee [7]
2176
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
2008 SPARKy Below knee [8]
2008 IPAM (intelligent Prosthesis using Below knee [9]
Artificial Muscles)
2009 Vanderbilt Transfemoral Prosthesis Above and Below knee [10]
2010 PANTOE 1 Below knee [11]
2011 SmartLeg Above and Below knee [12]
2012 AMP-foot 2.0 Below knee [13]
2013 Vanderbilt Transtibial Prosthesis Below knee [14]
2013 Cyberleg alpha Above and Below knee [15]
A. Upper knee prosthesis
Current prosthetics which are commercially available can be classified into different categories. Mainly there are
three types, mechanically passive devices, microprocessor-controlled passive devices, and powered devices [16].
Studies show that comparing to the conventional passive prosthesis, a computerized prosthesis provide more
degree of freedom and perfect gait conditions while consuming less energy. There are prosthetics available for
each part of the leg. This includes hip, femur, thigh, knee, etc.
1) Prosthetic Knees: Knee is one of the most complex and stressed joints in the human body. It is essential
for the movement and very vulnerable to get injured. So, any alteration in the join can cause an enormous change
in the patient’s gait [17]. The design of prosthetic knees is of two types. They are endo-prosthetic knees and exo-
prosthetic knees. Endo-prosthetic knees are usually surgically implanted in the patient’s body, whereas Exo-
prosthetic knees are fitted outside the amputee’s body cavity [18]. Exo- prosthetics can be further divided based
on their mechanism as Active and Passive. The active mechanism is expensive, but they are more adaptable to
different walking speeds [19]. There are different options for the passive mechanism, with various types of control
levels, and they provide great assistance to amputees. An active or powered prosthetic knee is more similar to the
biological human knee than the passive one. Hence, a powered prosthetic knee will be able to provide more
efficient movement and gait [20].
Another popular mechanism for the prosthetic knee is Poly- axial knee with multiple centers. An example of
this type is Ossur Total Knee [21] [22]. This type is based on a four-bar mechanism. In some developing countries
like India, the four-bar polycentric joint developed by D-Rev [23] has been widely used recently. And it has
provided better assistance compared to the single-axis joints. Low-cost passive mechanisms that aim to facilitate
able-bodied kinematics have also been introduced in India. For example, in India, a model has been developed
using an automatic early stance lock, a linear spring, and a differential friction damping system [24]. It provides
better stability, especially in the swing phases.
Six bar linkage has also been successfully used in some prosthetic knees. It has more design variables than the
four-bar mechanism. Hence, the six-bar mechanism can be more functional [25]. In some recent researches,
current prosthetics, especially the six-bar mechanisms, are assessed by Design for Manufacture and Assembly
(DFMA) method. Also, the static strength model can be evaluated by the Finite Element Method (FEM) [26].
Some finite element models of the prosthetic knee are constructed by applying the Reverse Engineering method
[27]. In this method, initially, the prototype is built by using IMAGEWARE and PRO/E. Secondly, based on the
CT image, the parts are developed and finally, all the models are assembled.
The microprocessor technology allows the knee to respond instantly to the change in speed [28]. So it has been
used in the most sophisticated prosthetic knees. Studies [29] have shown that the microprocessor-controlled knees
are superior to that of conventional mechanical knees in case of performance. Comparing to other types, the
microcontroller-based knees are having intelligent sensor and control systems. The mechanical structure of the
microprocessor-controlled prosthetic knee [30] is represented in fig.1. That means providing normal and safe gait
with very little energy consumption. The sensor system can detect the walking speed and gait phase. Also, the
force-sensitive resistors and multi-axis force sensors such as the six-axis force sensor, are present in some models
[30]. Microprocessor-controlled prosthetic knees can be again divided into variable-damping or semi-active
prosthetic knee.
2177
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
Fig. 1. The mechanical structure of the microprocessor-controlled prosthetic knee [30]
2) Prosthetic Hip: The hip joint is one of the most essential structures of the body as it supports the body
weight in both the static and walking postures. Since it is the largest weight-bearing joint, the design of the hip
joint should resist the fatigue failure of the hip [31]. It should also minimize the wear in the ball and socket [32].
The stress in the join can be reduced by increasing in contact area on the wear of socket and also by uniformly
distributing the load the contact area [33].
Hip replacements are realized with different kinds of materials, which are biocompatible, resisting heavy stress,
withstanding static and dynamic loads, and reducing frictional forces. Even certain combinations of metals,
ceramics, and polymers are used [34]. Frequently used materials are titanium alloys, stainless steel, special high-
strength alloys, alumina, zirconia, zirconia toughened alumina (ZTA), and UHMWPE [35]. Basically, the
surgically implanted replacement should perform all the functions of natural one, and the replacement surgery is
called Total Hip Arthroplasty (THA) or Total Hip Replacement (THR) [36]. A hip prosthetic usually consists of a
femoral head, a femoral stem, an acetabular cup, and a fixation agent that connects the acetabular cup into the
acetabulum of the pelvis and femoral stem into femur [37]. This is in the case of THR, but in the case of partial
knee prostheses, only the femoral head is replaced. The hip resurfacing procedure also exists where the femoral
head is reshaped. But some complications can occur in all these types of prostheses. An ideal prosthetic hip should
be able to replace the mechanism structure and assistance the original joint has been providing [38].
Hip prosthetics can be cemented or cement-less. Both models have their advantages and disadvantages. The
prostheses can be modeled and assembled to perform Finite Element Analysis [39]. Studies show that according
to the expectations of the amputees, some innovations such as shock absorption systems, wear resistance features,
adjustable offsets, and model parts with adjustable parameters have been introduced [37][40].
3) Prosthetic Femur: Reconstruction or prostheses of the femur bone can be done by several surgical options.
Endo- prostheses are mainly done in the case of a tumor, and generally, it is called Total Femoral Replacement
(TFR) [41]. TFR found to be effective in limb salvage [42].
A prosthetic femur must be having a stem with distal and proximal ends. The available designs of prosthetic
femurs are modeled in such a way that it provides medial-lateral fixation stability [43]. A collar is present on the
proximal end, which has a distally facing surface [44].
Most of the femoral prosthetics designs have been developed with a short stem. Clinical trials and FEA show
that these short stems preserve bone stock [45]. The analysis of femur bone prosthetic comprises the Compression
test of the femur bone, Scanning and modeling, Material selection, and Static structural analysis [46]. When it
comes to material selection, the selected materials should fit with the required properties [47] [48]. Titanium alloys
are preferable in this case [49] [50].
2178
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
B. Below knee prosthesis
A trans-tibial prosthesis consists of several divisions that help in the suspension of the prosthesis on the residual
limb. The major parts are a socket, a pylon, a foot, and a suspension for the prosthesis. Before the suspension of
the prosthesis, a liner is fitted to the patient to provide cushioning between the residual limb and the socket. The
liner can be made of different materials such as polyurethane and silicone known for its resistance [51]. Describing
in detail about three major socket designs used for Trans-tibial prosthetics, which are Patella Tendon Bearing
(PTB), Silicone Suction Suspension (3S), and Vacuum-Assisted. Fig. 2 shows a below-knee prosthesis device
(CYBERLEG alpha) [52].
Fig. 2. Below-knee Prosthesis CYBERLEG alpha [52]
1) Patella Tendon Bearing (PTB): These prosthetics is designed to place the weight bearing below the
patella. The suspension offered is generated by a belt that is tightened around the amputee part of the thigh. The
most common error made with PTB socket is the excessively tight fit in the popliteal area of the stump [53]. To
make the area for pressure against the popliteal surface of the stump larger, the back of the socket is extended to
increase the space between the hamstring tendons, cutting grooves so that it relieves the tendons during knee
flection. The unloaded prostheses will lean forward with the pylon inclined 2-3 degrees, depending on the heel-
cushion stiffness [54]. When the bodyweight is supported in the socket, and the pylon is vertical, the heel should
be compressed enough to supply approximately one-third of the total support from the foot, with the other two-
thirds being provided by the ball of the foot. Regardless of the fitting method employed, the socket for any patient
must provide the same overall functional characteristics, including comfortable weight-bearing, narrow base gait,
and as normal swing phase as possible consistent with the residual function available to the amputee after
amputation [55].
The PTB socket is considered to be suitable for the primary amputees as the socket can be modified to
accommodate any changes in the fixture in 12-18 months after the amputation. It is possible to relieve such areas
more quickly than in a total surface bearing style socket if the amputee has a particular area of sensitivity on their
residuum. The inner liner and hard outer socket of the PTB socket allow build-ups to be applied to the inner liner,
making it easier for donning and doffing for an amputee with a bulbous residual limb [56] [57]. There are few
contradictions to the PTB socket for current users. Active amputees find PTB socket trim lines and the suspension
offered by the PTB too restrictive to knee flexing. Other than the trim lines and suspension, few users also struggle
to find comfort due to the pressure applied on their patella tendon with is required for efficient operational
functioning of the PTB. Inaccuracies have been reported using FSR [58]. The transducers were calibrated in situ,
while it is attached to the inner socket of the transtibial socket. A Vanderbilt transtibial prosthesis model [59] is
shown in Fig. 3.
2179
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
Fig. 3. Vanderbilt Transtibial Prosthesis model [59]
2) Silicone Suction suspension (3S): To attain the desired suspension, a precise and exact fit of the Surlyn
socket was necessary, for which multiple fittings of transparent check sockets were also used, for which the process
required fitting as many as six check sockets for each prosthesis. To enhance the comfort of the patient, a pin that
engages a ring in the end of the silicone liner is used to secure the prosthesis. This indeed has proven to be quite
well accepted by the patients fit, and with practice, they can engage the ring in the first try of the patient [60]. The
fit of a Silicone Suction Socket has few necessary steps like firstly the prototype is to be fitted with a transparent
socket and distal end chamber. A link between the liner and the socket is then established dynamically during
patient fitting with the aid of compliant silicone gel.
The negative impression is set up beforehand in proper alignment on a flat surface with respect to the parasagittal
line drawn. The proximal portion is aligned on top of a Plaster of Paris (POP) distal extension block in proper
bench alignment after the cast is cut into two parts along the axis drawn. The distal extension block is pre-shaped
to accept a coupling ring. This coupling ring allows the socket to be connected to a VAPC gold alignment unit I
the assembly of a prototype prosthesis [61]. There is a critical factor in the alignment of the leg. It was the outset
if the foot was directly placed in the socket during weight-bearing a sideways shift to the socket occurred, tipping
the socket against the stump, causing excessive pressure. In this regard, the suction socket wearer walks differently
from the amputee wearing side hinges on a corset [3] [53] [62]. If at all the suction is lost, it would not be a severe
problem, as the leg falls off the stump. This can be handled by wearing a light strap around the stump, which holds
on to the leg if in case of loss of suction. The suction below-knee prostheses are unique in that they do not require
auxiliary suspension systems such as straps, cuffs, thigh lacers, to maintain the socket to the residual limb [63].
Active amputees gain from the lower trim lines possible with 3S design. Proprioception is increased due to
weight-bearing over the entire residual limb and proper pressure distribution at the socket walls. It is believed that
the overall socket pressure is reduced due to the entire surface of the residual limb accepting the weight in the 3S
socket. Few disadvantages, such as the 3S sockets, are not recommended to amputees with visual disturbances as
it may lead to more difficult donning and doffing that the PTB socket and amputees with excessive soft tissue
may find it more challenging to get comfortable due to the creasing of the silicon liner.
3) Vacuum-Assisted: This method is also known as negative pressure, elevated vacuum, or dynamic vacuum.
The suction suspension is created with direct contact between the liner and the socket wall. This system uses a
mechanism or pumps that suck the air between the liner and socket, creating a negative pressure that is the same
across the entire surface of the stump. To seal off the system by not allowing the negative pressure to be affected,
an external sleeve or seal is used at the top of the socket. Among all the new suspension options, Vacuum Assisted
sockets permit the least amount of pistoning within the socket [64]. This statement was proved when Kahle
described an agreement between two high-quality level - 2 and one low-quality study offered grade B evidence
that vacuum-assisted socket reduces movement of the residual limb within the socket. These modern systems
provide improved suspension in comparison with the historical standards of sleeve suspension and supracondylar
suspension. Upon extensive study in this topic in the past, authors have cumulated a well-defined set of potential
2180
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
benefits associated with this socket suspension system. Few of the benefits include a decrease in the daily
volume of changes as well as the maintenance of a better socket fit.
C. Orthotics
A literature review of the current orthotics was conducted, which helped understand their design constraints,
performance, and limitations. Most of the knee orthoses were to assist people with quadriceps muscle weakness
(QMW) [4],[65], [66], stroke patients [67], [68], [69] elderly people [70], [71], [72], [73] and in gait
rehabilitation [74], [75], [76], [77], [78], [79], [80], [81], [82], [83], [84].It is also designed for paralyzed people
and lower- limb amputees [85], [86]. These devices assisted patients with their knee flexion and extension
movements [75], [76], [80], [87], gait movements and raising mobility tasks as well. Various forms of knee
orthoses are available in the market. It includes Knee-Ankle-Foot Orthoses (KAFO), Stance- control KAFO
(SCKAFO), Powered Knee Orthoses (PKO), robotic assists, exoskeletons, etc. Various mechanical and
biomechanical tests are carried to understand the performance of the devices. Most of the biomechanical tests
consist of a walking test [4], [70], [72], [81], [82], [85], [88], [89], [90], [91] where the individual is asked to
walk a certain distance with and without the orthotic device. The results are then compared for the evaluation. Sit-
stand and stand-sit tests [65], [68], [73], [91], [92] are also performed to check the locking system performance
which helps in gait assistance by providing a locking mechanism during weight acceptance phase and allowing
free knee flexion during the swing phase. Treadmill experiments [69], [70], [77], [78], [81], [82], [89], [92] are
carried out to verify the ground reaction forces. The important measured parameters are gait speed and gait pattern.
It also evaluates the difference in knee angle with the applied torque. Patient comfort is another essential parameter
that is considered. They test muscle movements using an EMG [65], [66], [67], [70], [73], [77], [83], [84], [87],
[93]. The unit integrates various sensors to calculate the appropriate parameters. Table-2 explains the various
types of sensors and their positions, which are used in various orthotic studies.
Table 2: Sensors used in different orthoses
Sensor Type Sensor Location Reference
Potentiometer Ankle or Knee [19], [20], [24], [28], [29], [30], [32], [37], [44]
Accelerometer and/or Shank and/or thigh [33], [36], [48]
gyroscope
Force Sensitive Resistors Sole of foot [20], [24], [25], [30], [33], [39], [44]
Force sensors Knee [23], [48], [50]
EMG Other [16], [24], [29], [30], [31], [38], [39], [40], [42],
[43], [48], [49]
Inertial measurement Thigh or hip or foot [28], [30], [37], [38], [39], [44], [45]
units (IMU)
Strain gauge goniometer Knee joint [21], [30], [32]
Hall effect sensors Knee joint [30], [32]
Pressure sensors Foot [33], [37], [41], [45], [48]
In most knee orthotic devices, the PID controller is used as a controller [68], [70], [72], [77], [79], [80], [86].
Motion cameras and video cameras are used to analyze the motion of the individual [4], [65], [69], [86], [94].
Some experiments use optoelectronic measurement systems to assess the kinematics and kinetics of the human
body accurately [74].
2181
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
Fig. 4. KEA prototype mounted on a standard KAFO with articulating ankle joints [65]
1) KAFO: Knee-Ankle-Foot Orthoses are full leg braces intended for individuals with knee extensor weakness.
There are three types of KAFOs – passive, stance control KAFO (SC-KAFO), and active devices. Passive KAFOs
or conventional KAFO designs provide stability throughout the stance by locking the knee joint at a particular
angle. This can lead to an inefficient pattern of gait and hip hiking. SC- KAFOs overcomes passive device
limitations. They mimic the biological spring-like function of the knee by integrating spring-loaded knee locking
mechanism, which supports during the weight acceptance phase and thus allows free movement during the
swing phase of the gait. Active KAFO devices comprise actuators which provide additional power to replicate the
patterns of physiological gait. Knee-extension assist (KEA) was a type of KAFO designed for everyday use and
assisted individuals with difficulty performing stand-to-sit and sit-to-stand mobility tasks. The KEA prototype
mounted on a standard model KAFO with an articulating ankle joint is shown in Fig.4 [65]. The main objective
was to provide an external knee-extension moment to KAFO [66]. These devices undergo both mechanical and
biomechanical tests to understand their performance and viability. Depending on the features of the device,
biomechanical tests include ground-level walking, stair-descent, stand-sit, and sit-stand trials. For patients with
spinal cord injury, passive knee orthoses that utilize functional electrical stimulation (FES) cycling has been
developed to improve motor function [95].
SCKAFO or stance controlled SCKAFO uses microprocessor control, has a more reliable switching mode, and
has multiple settings for different types of terrain. A design named Ottawalk-Variable Speed (OWVS) aims to
provide variable knee flexion resistance and increase mobility in daily activities [4]. Quasi-passive architectures
have been developed to minimize the weight and power requirements. A Quasi- Passive Compliant Stance Control
Knee-Ankle-Foot Orthosis implements a linear spring in parallel to the impaired knee joint, which compliantly
supports the motion during the stance phase. It then enables the leg to swing freely to initiate the next step. The
design consists of a compliant stance control module (CSCM) incorporated into a standard KAFO. Various tests
were carried out to determine and evaluate the reliability, latency, resilience, and dynamic performance of the
developed model [2], [88]. An Automated Stance Controlled Knee-ankle- foot orthosis (ASCKAFO) controls the
2182
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
stance phase using an integrated actuator system with a set of sensors. They match the gait events that occur
naturally to solve other design weaknesses. Thermoplastic materials have been utilized in designing the model.
Several tests were carried out to access the precision and efficiency of the materials and components to be used
[74].
Active KAFOs consist of actuators that provide power during the push-off phase, which needs the highest energy
expenditure. Thus, active devices, compared to walking with passive devices, minimize the additional metabolic
activity arising from compensatory strategies. One such project under active orthosis was CYBERLEGs. They
developed a compact robotic ortho-prosthetics for functional replacement and assistance at lower-limbs. They were
able to assist actively with everyday activities [85]. Several active orthoses help to strengthen knee movements for
weak knee extensor patients and others that provide walking assistance knee joint rehabilitation [70], [86].
2) Powered Knee Orthosis (PKO): Powered Knee Orthoses are portable devices used in rehabilitation therapies
for gait assistance [71]. Most of the existing PKO systems are either equipped with complex hydraulic, pneumatic,
or more compact electric motor functions. Most orthoses are powered by a few combinations of geared with
electromagnetic motors. Fig. 5 shows a developed PKO device with gearbox [76]. The crucial aim of these devices
is to improve the back-drivability and produce high torque without using any controller with the actuator. Back-
drivability is the functionality of a motor that is gear- driven, with the load attached even if the external power is
removed. These devices were actuated using brushless DC motors (BLDCM) [75], [76], [93], which offered more
advantages over the conventional one. These PKO devices were able to provide back-drivability by performing
knee extension, and knee swing with the actuator turned off. The higher applied torque allowed faster knee
movement [75], [76]. PKO is also used to control the hip and knee angles for gait assistance. This algorithm
analyses the individual’s kinematic gait model, and the desired knee joint angle is estimated from the hip joint
angle measurements [72]. EMG monitored PKO system provides assistive commands according to the user’s
motion intention, which is tracked by EMG signals [77], [82]. Electronic and control architecture based powered
orthosis for knee has also been designed for gait rehabilitation [78].
Fig. 5. A developed PKO device with gearbox [76]
3) Robotic assistive devices: Numerous studies have reported the effects of a rehabilitation robot. One such design
developed is Robot KAFO, which is a robot rehabilitation device attached to an ordinary Knee-Ankle-Foot
Orthosis. This device’s principal objective is to assist the knee movements, observe kinematic patterns, and muscle
activation during gait [67]. The use of robotic devices for physiotherapy allows performing exercises regularly
[96]. A design based on adaptive impedance control was developed considering the highly challenging locomotive
tasks for repetitive rehabilitation training, which provides a more comfortable and natural motion. The proposed
strategy applies a speed-dependent walking pattern and estimates the robotic stiffness associated with the interaction
of human orthosis by observing the interaction torque at knee joints at different knee angles. It was validated that
the robotic stiffness modulation based adaptive control strategy was able to recognize and customize the therapy
according to the user’s effort [79]. Another robotic device called COWALK-M was designed to assist stroke
2183
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
patients with mild hemiplegia to move the paretic knee joint during daily activities [89].
4) Exoskeletons: Exoskeletons were explicitly designed for stroke survivors. They are also used to retrain the
neural system of people with paraplegia. Exoskeletons utilize mechanical actuators to help patients generate gait
patterns and provide functional benefits to the users. Knee strength is highly correlated with the ability to perform
independent sit-stand motions. An exoskeleton was developed to restore symmetry and to provide external
assistance. A knee exoskeleton actuator that uses fiberglass leaf spring has been designed to improve torque control
and thus assist the sit-stand movements [68]. Another novel hybrid device called FEXO has been developed that
combines Functional Electrical Simulation (FES) with a compliant exoskeleton that focuses on controlling the
rhythmic movements of the knee. The motion pattern of the knee angle per torque applied is observed for the
evaluation of FEXO [80]. A power-assisted pneumatic-based exoskeletal system for gait rehabilitation was
developed for rehabilitation that helps the users in gait assistance [81]. An exoskeleton system to assist patients
for lower limb movements is available in the market [87], [90].
Lower limb orthotic devices were also developed for gait assistance. It assesses the sensitivity and relative timing
of the system of sensors used in the device [91]. One such design uses pneumatic artificial muscles as actuators
[97]. Knee orthotic device has been developed with variable stiffness and damping to simulate hemiparetic gait.
It also tested for the orthosis effect on the dominant and non-dominant limbs [69]. Digital Goniometers can be
used for measuring the knee-joint position that helps in the application of orthosis [94].
IV. LIMITATIONS AND SCOPE FOR IMPROVEMENT
Different scholars have looked differently at the relationship between beneficial pressure distributions, skin
irritation, and wound healing. The synthesis between these two views is obtained in an understanding that
decreased pistoning decreases the shearing forces, which, in turn, reduces the incidence of skin disruption and
pain. Detaining the movement of the limb within the socket may lessen the irritation over both healthy and
ulcerated tissues, allowing for granulation and healing of existing wounds. Despite the benefits associated with
vacuum-assisted sockets, it is not universally indicated [64]. Supporting to this context, many have reported
specific problems caused by the use of vacuum-assisted socket like skin blisters during improper wear. In addition
to this, vacuum-assisted sockets also require higher maintenance when compared to other suspension systems.
All orthotic devices are developed to assist people with walking disabilities. They help in gait assistance by
supporting the person during the weight acceptance phase and allowing movement during the swing phase.
Bulkiness is the major limitation of the orthotic devices. The bulkier the design is, the less comfortable it is to the
user. Another limitation is that some devices often exhibit a delay in the gait assistance, which hinders the regular
gait pattern leading it to a slower and uncomfortable outcome. Most of the testing process is done on healthy
individuals. Testing on patients who needs gait assistance could infer better results. Detailed gait function must
be assessed rather than just gait speed and number of steps for better interpretation of results
The future scopes of these orthotic devices are described below. A small and light-weighted design could be
developed, which provides excellent patient comfort. Conducting tests of the devices on impaired volunteers helps
to examine the performance of the system in its expected scenario. Making the devices portable for long-distance
walking and providing more significant force for gait assistance makes them more user-friendly. Further
improvement must be made for the speed of the device such that it assists the patient during gait without any delay.
V. CONCLUSION
This paper gives a wide review about the types, methods, and recent developments in lower limb prosthetics and
orthotics. Various prosthetic and orthotic devices have been discussed in this systematic literature study. These
devices help people with disabilities and amputees by providing them with gait assistance and thus have a
significant role in gait rehabilitation. Different types of above-knee prosthetics, including knee, hip, and femur,
and their mechanisms have been discussed. The types of sockets used in the below-knee prosthesis have also been
described in detail. Under orthotic devices, the different mechanisms of KAFOs have been analyzed and compared.
Electromyography (EMG) is used in several mechanisms to examine the effect of these devices on muscle
activations.
VI. REFERENCES
[1]. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Sim- mons AL. Open tibial fractures with severe soft-
2184
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
tissue loss. Limb salvage compared with below-the-knee amputation. 1993.
[2]. Shamaei K, Napolitano PC, Dollar AM. Design and Functional Evaluation of a Quasi-Passive Compliant
Stance Control Knee–Ankle–Foot Orthosis. IEEE Transactions on Neural Systems and Rehabilitation
Engineering. 2014; 22(2):258-268.
[3]. Cohen SI, Goldman LD, Salzman EW, Glotzer DJ. The Deleterious Effect of Immediate Postoperative
Prothesis in Below-Knee Amputation for Ischemic Disease. 1974.
[4]. Herbert-Copley A, Lemaire ED, Baddour N. Evaluation of a Variable Resistance Orthotic Knee Joint. 38th
Annual International Conference of the IEEE Engineering in Medicine and Biology Society. :2016-2016.
[5]. Au SK, Dilworth P, Herr H. An ankle-foot emulation system for the study of human walking biomechanics
in Proceedings-IEEE international conference on robotics and automation:2939-2984Institute of Electrical
and Electronics Engineers Inc 2006.
[6]. Martinez-Villalpando EC, Weber J, Elliott G, Herr H. Design of an agonist-antagonist active knee prosthesis.
in Proceedings of the 2nd biennial IEEE/RAS-EMBS international conference on biomedical robotics and
biomechatronics:529-563 2008.
[7]. Borjian R, Lim J, Khamesee MB, Melek W. The design of an intelligent mechanical active prosthetic knee
in Proceedings-34th annual conference of the IEEE industrial electronics society:3016-3037 2008.
[8]. Holgate MA, Hitt JK, Bellman RD, Sugar TG, Hollan- der KW. The SPARKy (spring ankle with regenerative
kinetics) project: choosing a DC motor based actuation method in Proceedings of the 2nd biennial
IEEE/RAS- EMBS international conference on biomedical robotics and biomechatronics:163-171 2008.
[9]. Versluys R, Desomer A, Lenaerts G, et al. A pneumatically powered below-knee prosthesis: design
specifications and first experiments with an amputee in Proceedings of the 2nd biennial IEEE/RAS-EMBS
international conference on biomedical robotics and biomechatronics:372-379 2008.
[10]. Sup F, Varol HA, Mitchell J, Withrow TJ, Goldfarb M. Self-contained powered knee and ankle prosthesis:
initial evaluation on a transfemoral amputee in 2009 IEEE international conference on rehabilitation
robotics:638- 682IEEE Computer Society 2009.
[11]. Zhu J, Wang Q, Wang L. PANTOE 1: Biomechanical design of powered ankle-foot prosthesis with compliant
joints and segmented foot. IEEE/ASME international conference on advanced intelligent mechatronics, AIM:
31- 37Institute of Electrical and Electronics Engineers Inc 2010.
[12]. Dedic R, Dindo H, Smartleg. bhT; m:tel-imate prijatelije; ENERGOINVEST-SUI-Sistemi upravljanja
energijom in 2011 23rd international symposium on information, communication and automation
technologies IEEE Computer Society 2011.
[13]. Cherelle P, Matthys A, Grosu V, Vanderborght B, Lefeber
[14]. The AMP-foot 2.0: mimicking intact ankle behavior with a powered transtibial prosthesis in Proceedings of
the IEEE RAS and EMBS international conference on biomedical robotics and biomechatronics: 544-
553IEEE Computer Society 2012.
[15]. Shultz AH, Mitchell JE, Truex D, Lawson BE, Goldfarb
[16]. M. Preliminary evaluation of a walking controller for a powered ankle prosthesis in Proceedings-IEEE
international conference on robotics and automation: 4837- 4880Institute of Electrical and Electronics
Engineers Inc 2013.
[17]. Geeroms J, Flynn L, Jimenez-Fabian R, Vanderborght B, Lefeber D. Ankle-knee prosthesis with powered
ankle and energy transfer for CYBERLEGs-prototype. IEEE international conference on rehabilitation
robotics ICORR 2013IEEE 2013.
[18]. Hargrove LJ, Member, Ieee H, et al. Senior Member, IEEE, Toward the Development of a Neural Interface
for Lower Limb Prosthesis Control. 31st Annual International Conference of the IEEE EMBS. 2009.
[19]. Ferber R, Osternig LR, Woollacott MH, Wasielewski NJ, Lee JH. Gait mechanics in chronic ACL deficiency
and subsequent repair. Clinical Biomechanics. 2002; 17(4):274-285.
[20]. Ramakrishnan MT, Schlafly KB, Reed. Evaluation of 3D Printed Anatomically Scalable Transfemoral
Prosthetic Knee. 2017 International Conference on Rehabilitation Robotics (ICORR) QEII Centre. 2017.
2185
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
[21]. Johansson JL, Sherrill DM, Riley PO, Bonato P, Herr H. A Clinical Comparison of Variable-Damping and
Mechanically Passive Prosthetic Knee Devices. American Journal of Physical Medicine & Rehabilitation.
2005; 84(8):563- 575.
[22]. Dabirl Y, Najarian S, Eslamf MR, Zahedt S, Farahpou H, Moradihaghighaf R. Comparison of passive and
active prosthetic knee joint kinematics during swing phase of gait. 2010.
[23]. Radcliffe CW. Four-bar linkage prosthetic knee mechanisms: Kinematics, alignment and prescription
criteria. Prosthetics and Orthotics International. 1994; 18(3):159- 173.
[24]. Sup F, Bohara A, Goldfarb M. Design and Control of a Powered Transfemoral Prosthesis. The International
Journal of Robotics Research. 2008; 27(2):263-273.
[25]. Hamner SR, Narayan VG, Donaldson KM. Designing for Scale: Development of the ReMotion Knee for
Global Emerging Markets. Annals of Biomedical Engineering. 2013; 41(9):1851-1859.
[26]. N V, Arelekatti M, Winter AG, V. Design of a Fully Passive Prosthetic Knee Mechanism for Transfemoral
Amputees in India. 2015. 2015 IEEE International Conference on Rehabilitation Robotics (ICORR).
[27]. Jin D, Zhang R. Kinematic and dynamic performance of prosthetic knee joint using six-bar mechanism.
Journal of rehabilitation research and development. 2003; 40(1):39- 48.
[28]. Ferryanto F, Muhammad KA, Rubiyanto T, Mihradi S, Mahyuddin AI. Design Modification of an Affordable
Prosthetic Knee Based on DFMA and Static Analysis. 2017. ICICI-BME Bandung.
[29]. Dong L, Wu D, Liu N, Ye J, Zhang C, Chen W. The Reconstruction of the Finite Element Model of Artificial
Knee Joint Based on RE Technology. 2009.
[30]. Torki AA, Taher MF. Abdalla Sayed Ahmed, Design and implementation of a swing phase control system
for a prosthetic knee. IEEE. 2008:8-8.
[31]. Taylor MB, Clark E, Offord EA, Baxter C. A comparison of energy expenditure by a high level trans-femoral
amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs. Prosthetics and
Orthotics International. 1996; 20(2):116-121.
[32]. Cao W, Yu H, Chen W, Meng Q, Chen C. Design and Evaluation of a Novel Microprocessor-controlled
Prosthetic Knees. 2019.
[33]. GRIZA S, KWIETNIEWSKI C, TARNOWSKI G, et al. Fatigue failure analysis of a specific total hip
prosthesis stem design. International Journal of Fatigue. 2008;30(8):1325-1332.
[34]. Wu JS, Hung J, Shu C, Chen J. The computer simulation of wear behavior appearing in total hip prosthesis.
Comput. Methods. Program. Biomed. 2003; 70:81-91.
[35]. Desai C, Hirani H, Chawla A. Life Estimation of Hip Joint Prosthesis. 2014.
[36]. Aherwar A, Singh AK, Patnaik A. Current and future biocompatibility aspects of biomaterials for hip
prosthesis. AIMS Bioeng. 2015; 3:23-43.
[37]. Merola M, Affatato S. Materials for Hip Prostheses: A Review of Wear and Loading Considerations. 2019.
[38]. Lee JM. The Current Concepts of Total Hip Arthroplasty.
[39]. Hip Pelvis. 2016; 28:191-200.
[40]. Derar H, Shahinpoor M, Open Biomed Eng J. Recent Patents and Designs on Hip Replacement Prostheses.
2015.
[41]. Harris C. Optimizing Production of Serially Diluted Compounds and Distribution to Multiple Targets. Journal
of the Association for Laboratory Automation. 2001; 6(1):58-60.
[42]. Çelik T, Kişioğlu Y. Evaluation of new hip prosthesis design with finite element analysis. 2019.
[43]. Rao S, Goli GV, K A. Modular hip implant with shock absorption system U. S. Patent. 2002; 6:941-942.
[44]. Toepfer A, Harrasser N, Petzschner I, et al. Is total femoral replacement for non-oncologic and oncologic
indications a safe procedure in limb preservation surgery? A single center experience of 22 cases. 2018.
[45]. Wu F, Fang X, Lang Z, Liu H, Duan H. Advances in Total Femur Replacement 2018.
[46]. Haines TG, Biomet Manufacturing LLC. Femoral prosthetic implant, US8430932b2.
2186
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
[47]. Boucher F, Munting E, ORTHONOVA Sas Stryker European Holdings I LLC. Femoral prosthesis,
US20090088863a1. 2008.
[48]. Mercur M, Falez F, Vaienti F, et al. Short stem femoral prosthesis US20080119942A1. 2006.
[49]. Javir AV, Kirkire MS. Finite Element Analysis of Femur Prosthesis. International Conference on Nascent
Technologies in Engineering (ICNTE).
[50]. Elias CN, Lima JHC, Mayers MA. Biological applications of titanium and its alloys. Biological Materials
Science. 2008.
[51]. Mohsin T, Mohammed ZA, Khan AN, Siddiquee. Titanium and its alloys, the imperative materials for
biomedical applications. International Conference on Recent Trends in Engineering & Technology.
2012:978-81.
[52]. Hanumantharaju HG, Shivanand DHK. Static analysis of Bi-Polar femur bone-implant using FEA.
International Journal of Recent Trends in Engineering. 2009; 1(5).
[53]. Tschegg EK, Lindtner RA, Doblhoff-Dier V, et al. Characterization methods of bone–implant-interfaces of
bioresorbable and titanium implants by fracture mechanical means. Journal of the Mechanical Behavior of
Biomedical Materials. 2011; 4(5):766-775.
[54]. Emrich R, Slater K. Comparative analysis of below-knee prosthetic socket liner materials. Journal of Medical
Engineering & Technology. 1998; 22(2):94-98.
[55]. Geeroms J, Flynn L, Jimenez-Fabian R, Vanderborght B, Lefeber D. Ankle-Knee prosthesis with powered
ankle and energy transfer for CYBERLEGs α-prototype in 2013 IEEE 13th International Conference on
Rehabilitation Robotics (ICORR):1-6 2013.
[56]. Foort MAJ. The Patellar - Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique
and Criteria. 1965.
[57]. Radcliffe CW, Froot J. The patella tendon bearing below-knee prostheses. 1961.
[58]. Schuch CM. Modern above-knee fitting practice (A report on the ISPO workshop on above-knee fitting and
alignment techniques May 15–19, 1987, Miami, USA. Prosthetics and Orthotics International. 1988;
12(2):77- 90.
[59]. Kristinsson O. Pressurised casting instruments, Proceedings of the 7th World Congress, International Society
of Prosthetics and Orthotics. 2002.
[60]. AWP B. Dynamic interface pressure measurement: comparing 2 transtibial socket concepts. 1997.
[61]. Convery P, Buis AWP. Conventional patellar-tendon- bearing (PTB) socket/stump interface dynamic
pressure distributions recorded during the prosthetic stance phase of gait of a transtibial amputee. 1998.
[62]. Shultz AH, Mitchell JE, Truex D, Lawson BE, Goldfarb M. Preliminary evaluation of a walking controller
for a powered ankle prosthesis in 2013 IEEE International Conference on Robotics and Automation:4838-
4843 2013.
[63]. Fillauer CE, Pritham CH, Fillauer KD. Evolution and Development of the Silicone Suction Socket (3S) for
Below-Knee Prostheses. 1989.
[64]. Murphy EF. The fitting of below-knee Prostheses, Human limbs and their Substitutes. 1968.
[65]. Galdik J. The below-knee suction socket.
[66]. Staats TB, Lundt J. The UCLA Total Surface Bearing Suction below-knee Prostheses. 1964.
[67]. Stevens PM, DePalma RR, Wurdeman SR. Transtibial Socket Design, Interface, and Suspension. 2019.
[68]. Spring AN, Kofman J, Lemaire ED. Design and Evaluation of an Orthotic Knee-Extension Assist. IEEE
Transactions on Neural Systems and Rehabilitation Engineering. 2012; 20(5):678-687.
[69]. Spring A, Kofman J, Member. Knee-Extension-Assist for Knee-Ankle-Foot Orthoses. 33rd Annual
International Conference of the IEEE EMBS. 2011.
[70]. Shihomi K, Koji O, Tadao T, Yuichi S, Yoshiyuki H. Development of new rehabilitation robot device that
can be attached to the conventional Knee-Ankle-Foot-Orthosis for controlling the knee in individuals after
stroke. International Conference on Rehabilitation Robotics (ICORR). 2017.
2187
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
[71]. Shepherd MK, Rouse EJ. Design and Characterization of a Torque-Controllable Actuator for Knee
Assistance during Sit-to-Stand. 38th Annual International Conference of the IEEE Engineering in Medicine
and Biology Society (EMBC). 2016.
[72]. Lahiff CA, Ramakrishnan T, Kim KSH, Reed. Knee Orthosis with Variable Stiffness and Damping that
Simulates Hemiparetic Gait. 37th Annual International Conference of the IEEE Engineering in Medicine and
Biology Society (EMBC). 2016.
[73]. Shan H, Jiang C, Mao Y, Wang X. Design and Control of a Wearable Active Knee Orthosis for Walking
Assistance. IEEE Advanced Motion Control. 2016.
[74]. Ma H, Lai WY, Liao WH, Fong DTP, Chan KM. Design and Control of a Powered Knee Orthosis for Gait
Assistance. IEEE/ASME International Conference on Advanced Intelligent Mechatronics (AIM). 2013.
[75]. Lai WY, Ma H, Liao WH, Fong DTP, Chan KM. HIP- KNEE Control for Gait Assistance with Powered Knee
Orthosis. Proceeding of the IEEE International Conference on Robotics and Biomimetics (ROBIO). 2013.
[76]. Mefoued S, Mohammed S, Amirat Y, Fried G. Sit-To-Stand Movement Assistance Using an Actuated Knee
Joint Orthosis. The Fourth IEEE RAS/EMBS International Conference on Biomedical Robotics and
Biomechatronics. 2012.
[77]. Alotaibi H, Algholaiqah L, Abusibi W, Saleh G, Automated Stance Controlled-Knee-Ankle-Foot Orthosis
2019.
[78]. Yusof A, Che-Ani A, Hussain Z, Hamzah N, Yahaya SZ. Design and Development: Actuator of Powered
Knee Orthosis a Prototype. 6th IEEE International Conference on Control System, Computing and
Engineering. 2016.
[79]. Yusof AS, Che-Ani AI, Hussain Z, Hamzah N, Boudville R, Rahman MFA. Back-Drivability of Powered
Knee Orthosis for Knee Free Swing and Knee Extension. 7th IEEE International Conference on Control
System, Computing and Engineering. 2017.
[80]. Fernandes PN, Figueredo J, Moreira L, et al. EMG-based Motion Intention Recognition for Controlling a
Powered Knee Orthosis. 2019 IEEE International Conference on Autonomous Robot Systems and
Competitions (ICARSC). 2019.
[81]. Félix P, Figueiredo J, Santos CP, Moreno JC. Electronic Design and Validation of Powered Knee Orthosis
System embedded with Wearable Sensors. IEEE International Conference on Autonomous Robot Systems
and Competitions (ICARSC). 2017.
[82]. Figueiredo J, Félix P, Santos CP, Moreno JC. Towards Human-Knee Orthosis Interaction Based on Adaptive
Impedance Control Through Stiffness Adjustment. International Conference on Rehabilitation Robotics
(ICORR). 2017.
[83]. Ren Y, Zhang D. FEXO Knee: A Rehabilitation Device for Knee Joint Combining Functional Electrical
Stimulation with a Compliant Exoskeleton. 5th IEEE RAS & EMBS International Conference on Biomedical
Robotics and Biomechatronics (BioRob). 2014.
[84]. Zhenyang W, Chunman T, Zheng Y, Chong. Power Assisted Pneumatic-based Knee-Ankle-FootOrthosis for
Rehabilitation. IEEE EMBS International Conference on Biomedical Engineering and Sciences. 2012.
[85]. Félix P, Figueiredo J, Santos CP, Moreno JC. Powered Knee Orthosis for Human Gait Rehabilitation: First
Advances. IEEE 5th Portuguese Meeting on Bioengineering (ENBENG). 2017.
[86]. Sabino A, Boiczyk G, Almakrami H, et al. The Development of a Robotic Walk-Assist Device for
Rehabilitation in Patients with Lower Extremity Paralysis. IEEE International Conference on Automation
Science and Engineering (CASE). 2016.
[87]. Cantu C, Tamez-Duque J, Shimoda S, Soto R. Design of a control system for a knee rehabilitation orthosis
using a recovery status. 2017 International Symposium on Wearable Robotics and Rehabilitation (WeRob).
2017.
[88]. Sanz-Morère CB, Fantozzi M, Parri A, et al. A Bioinspired Control Strategy for the CYBERLEGs Knee-
Ankle-Foot Orthosis: Feasibility Study with Lower Limb Amputees. 7th IEEE International Conference on
Biomedical Robotics and Biomechatronics (Biorob). 2018.
[89]. Poonsiri J, Rachagorngij M, Charoensuk W. Biomechanical Based Design of an Active Knee Ankle Foot
2188
JOURNAL OF CRITICAL REVIEWS
ISSN- 2394-5125 VOL 7, ISSUE 15, 2020
Orthosis to Augment the Knee Motions. The 2014 Biomedical Engineering International Conference
(BMEiCON-20l4). 2014.
[90]. Hassani W, Mohammed S, ı HR, Amirat Y. EMG Based Approach for Wearer-centered Control of a Knee
Joint Actuated Orthosis. IEEE/RSJ International Conference on Intelligent Robots and Systems (IROS).
2013.
[91]. Shamaei K, Napolitano PC, Dollar AM. A Quasi- Passive Compliant Stance Control Knee-Ankle-Foot
Orthosis. IEEE International Conference on Rehabilitation Robotics. 2013.
[92]. Kim J, Kim SJ, Choi J. Real-time Gait Phase Detection and Estimation of Gait Speed and Ground Slope for
a Robotic Knee Orthosis. IEEE International Conference on Rehabilitation Robotics (ICORR). 2015.
[93]. Lu YY, Yen HC, Da-Chuan, Cheng ZY, Li. The Design of an Exoskeleton System Applied for Lower Limb
Paralysis. IEEE International Conference on Applied System Invention (ICASI). 2018.
[94]. Gawlik M, Sazonov E, Shen X. Sensor sensitivity to posture transitions in a lower extremity orthotic device.
Proceedings of the IEEE SoutheastCon. 2015.
[95]. Bell J, Shen X, Sazonov E. Early Detection of Sit-to-Stand Transitions in a Lower Limb Orthosis. 37th
Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). 2015.
[96]. Zhu H, Nesler C, Divekar M, Ahmad T, Gregg RD. Design and Validation of a Partial-Assist Knee Orthosis
with Compact, Backdrivable Actuation. IEEE 16th International Conference on Rehabilitation Robotics
(ICORR). 2019.
[97]. Dominguez G, Cardiel E, Arias S, Rogeli P. A Digital Goniometer Based on Encoders for Measuring Knee-
Joint Position in an Orthosis. 2013 World Congress on Nature and Biologically Inspired Computing. 2013.
[98]. Sousa ACCD, Cascas FS, Sousa A, Lanari BP. Simulation of the assistance of passive knee orthoses in FES
cycling. 41st Annual International Conference of the IEEE Engineering in Medicine and Biology Society
(EMBC). 2019.
[99]. Koller-Hodac A, Leonardo D, Walpen S, Felder D. Knee Orthopaedic Device How Robotic Technology Can
Improve Outcome In Knee Rehabilitation. IEEE Interna- tional Conference on Rehabilitation Robotics.
2011.
[100]. Gu Y, Lv Y, Ma X, Lu C. Lower-Limb Soft Orthotic Device for Gait Assistance. IEEE 4th Information Tech-
nology and Mechatronics Engineering Conference. 2018.
2189