For people with SCI, walking with braces can be tiring, and thus few people use them. Hybrid systems combine conventional bracing with FES to activate large lower extremity muscles in the hopes of improving the gait pattern and reducing upper extremity exertion. The FES is used to improve trunk and hip stability and to facilitate forward progression.
We found 6 post-test studies (Marsolais et al. 2000; Solomonow et al. 1997; Sykes et al. 1996a; Sykes et al. 1996b; Yang et al. 1996; Thoumie et al. 1995) that examined the combined effect of lower extremity bracing with FES on functional ambulation in people with complete SCI (aggregate N=115). Most studies found that the combination of long-leg bracing and FES may enable overground ambulation of between 180 and 1400 m at one time (Marsolais et al. 2000; Solomonow et al. 1997; Sykes et al. 1996a; Thoumie et al. 1995). There does not seem to further benefit in combining FES with orthosis-use in terms of maximal walking speed (Sykes et al. 1996b; Yang et al. 1996; Thoumie et al. 1995), although greater walking distance may be achieved (Marsolais et al. 2000; Thoumie et al. 1995). Three pretest/posttest studies (Marsolais et al. 2000; Yang et al. 1996; Thoumie et al. 1995); and one posttest study (Sykes et al. 1996b) directly compared the effect of bracing+FES with either FES or bracing alone. When subjects walked with either braces or FES alone, maximum walking distance ranged from 3 to 400 m. When braces were combined with FES, maximum distance increased to 200 to 1400 m (Marsolais et al. 2000; Sykes et al. 1996b; Thoumie et al. 1995).
Biomechanical studies (not included in the summary tables if they did not have a training period) provide some insight into the relative benefits of FES versus bracing. One study that compared FES-alone with bracing-alone found that FES provides a particular advantage in facilitating sit-to-stand movements and donning the system (Bonaroti et al. 1999). However, once standing was achieved, mobility (e.g., walking, stairs) was not found to be different between FES and bracing. For people with incomplete SCI, Kim et al. (2004) found FES produced more benefits in walking speed, and bracing (AFO alone) improved walking distance. However, the combination of AFO with FES improved gait benefits more than either device used alone (Kim et al. 2004).
There is level 4 evidence (Yang et al. 1996) that a combined approach of bracing and FES results in additional benefits to functional ambulation in paraplegic patients with complete SCI. However, in participants who achieve little benefit from bracing alone, the addition of FES appears to help improve standing or short-distance walking function (Marsolais et al. 2000). In incomplete SCI, however, there is some indication that a combination of bracing and FES provides greater ambulatory function than either approach alone (Kim et al. 2004).