Orthoses/Braces

There are several available devices used for bracing the legs in order to support standing and walking function, for both complete and incomplete SCI. These range from single-joint bracing (e.g. ankle-foot orthosis), which are usually for individuals with low, incomplete spinal lesions, to whole-leg/long-leg braces that extend from the lower back to the ankle. Reciprocating gait orthosis links the two leg braces together through a trunk/waist component and allows one leg to be flexed (progressed forward) while the reciprocal extension is generated in the other leg. Among the most common long-leg braces studied in the literature are the purely mechanical Parawalker (Rose 1979) or the Reciprocating Gait Orthosis (RGO) (Douglas et al. 1983). The RGO uses the flexion power of one hip to assist with extension of the opposite hip. These devices may also be combined with FES to augment gait function and efficiency (Marsolais et al. 2000; Yang et al. 1996; Nene and Patrick 1990). These devices must be used with a walking aid (e.g. crutches or walker) for functional ambulation. The braces for higher level complete lesions are costly and can be challenging to take on and off independently. The RGO and Para-step styles are not made to accommodate long periods of sitting so are used only for walking and are therefore are not very functional in everyday life for most people. The power assist or robotic exoskeletons are also emerging in some clinical settings with some indications that they may be applicable to assist with early mobilization of incomplete SCIs. Knee ankle-foot orthoses (KAFO) are also used with complete injuries and with these braces you can sit in a wheelchair and get up and down throughout the day without risk of skin issues if they are fitted properly. These can be appropriate for some individuals but there has been poor adherence over the long term. With these braces, people will walk with a swing through or reciprocal stepping style depending on the level of their injury. They require substantial upper body strength to achieve standing while walking long distances is not feasible. A swing through gait is very tiring on the upper extremities and a reciprocal gait is very slow so most people will opt for a wheelchair when long distances are required.

Many styles of AFOs and knee hyperextension braces are used to assist with standing and walking. These can be for joint protection when there is a significant muscle imbalance around a joint such as a knee hyperextension brace (Swedish knee cage or Ossur knee sleeve for example). Depending on an individual’s strength, tone, and range of motion there are a great deal of AFOs to use ranging from a dynamic small brace to assist with toe clearance like the Dictus to a more rigid custom AFO to stabilize and hold the entire foot and ankle. The more rigid a brace is the more that it will impede “ normal” dynamics around the joint although this may be clinically necessary to protect the joints and provide a safe stable base to weight bear on. These braces for the knee and lower leg may require a walking aid like the higher braces but may be able to be used without an aid. Braces have been advanced with powered actuators to reduce the effort required to advance the limb. Earlier models used actuators in single joints (e.g. ankle or hip), while newer models control multiple lower extremity motions. Some of the newest models utilize an exoskeleton with battery-powered motors to control multiple degrees of freedom and the weight of the device is transferred to the ground by the exoskeleton, alleviating the subject from bearing the weight of the device.