Therapeutic Gait Training

Therapeutic Application and
Gait Training
Stance control orthoses
E-MAG Active and Free Walk
| Information for orthotists and therapists |

Therapeutic Application and Gait Training
Preface
Walking freely places a high demand on an orthotic
system. The orthosis has to bear the patients full
body weight for a moment in the stance phase, while
also allowing for mobility of the knee joint during the
swing phase.
The development of knee joints that are movable
during the swing phase has ushered in a new era of
leg apparatuses. The Free Walk orthosis is the first
intelligent orthotic system that offers a broad range
of applications as well as ample experience.
Customized orthotic fitting requires lower leg
apparatuses that promote patients stance stability
and ability and that provide pain relief for arthroses
and neuromuscular diseases.
Mary Jerell reported in her survey in 2004 that 20%
of post-polio syndrome patients are candidates
for stance control orthoses. The case of this
neuromuscular disease shows that fitting patients
with orthoses with posteriorly placed Swiss locks
or lock rings should no longer be an acceptable
practice as these components unnecessarily
immobilize the knee joint. Rather, every fifth patient
could be fitted with an orthosis allowing the
knee joint to move in swing phase, which would
demonstrably improve their neuromuscular and
muscle-energetic gait pattern.
Patients fitted with swing-phase movable orthoses
are shown to expend less energy than patients with
rigid apparatuses. Moreover, they will also suffer
less damages of the locomotor system and large
joints.
However, the best intelligent leg orthosis is worthless

if professional and qualified explanations and
instructions for use are not complied with.
This brochure is not a comprehensive and complete
instructions for use manual. Rather, it aims to give
impulses and advice for experienced and less
experienced therapists for optimally fitting their
patients with an intelligent leg orthosis. To counter
the "well operated, but poorly mobilized" syndrome,
orthotic
fitting must comply with requirements and para
meters set by industry, orthotists, therapists and
treating physicians.
Our experience with Free Walk over the past three
years has shown that patients readily accept the
orthosis because of its form and weight. However,
the crucial factor for ultimately mobilizing the patient
is the therapists conviction and qualification. It does
not make sense to evaluate and possibly not favour
an extensive medical-technical product for reasons
of economy, arguing that therapeutic training is poor
or non-existent.
We recommend patients to test the limits of a swingphase movable leg orthosis for their daily activities,
such as sitting, climbing stairs, sitting down, getting
into cars, or doing sports. In that way, they will
realize the advantages of an intelligent orthosis
for their daily life. This test phase, that includes
applying, handling and walking with the orthosis, is
indispensable for all further success.
It is with great pleasure that I present this training

brochure. Long overdue, it will benefit the many
patients who have already been fitted with the
Free Walk and who, due to further developments
and changed indications and contra-indications,
require the experience of instructing therapists.
The brochure will be a valuable reference for both
patient and therapist, assisting them in the transition
to independent, daily use once the fitting by the
orthotist and physician is completed.
I wish all therapists and patients great success
with this brochure. Finally, I also encourage them to
assert their legitimate claim for a sufficient number of
therapy sessions that are to follow the fitting.
Dr. med. Axel Ruetz

Chief Physician Orthopaedics
Sankt Josef Brderkrankenhaus Koblenz

Contents
Preface
Page 2
Introduction
Page 5
Therapeutic Benefit
Page 6
Medical Indications
Page 7
Biomechanics of the Normal Gait
Page 8
Gait Cyle with the E-MAG Active and Free Walk
Page 9
Prerequisites and Targeted Therapy for the Application
Page 10
Handling of the Orthosis and First Exercises
Page 20
Specific Gait Training with Stance Control Orthoses
Page 24
Daily Life Activities
Page 30
Frequently Asked Questions
Page 33
Introduction
Stance control orthoses make it possible to walk
dynamically and stand securely during the stance
phase. The special Otto Bock orthosis systems lock
the knee joint during the stance phase and unlock it
for the swing phase. The patient thereby achieves a
dynamic, almost physiological gait pattern requiring
less energy.
With their function, the E-MAG Active and Free Walk
orthoses relieve the back, hips, and knee joint. In
different ways, because of the individual differences
of the orthosis systems, they provide the patient
with increased security, stability, and above all
greater mobility.
The E-MAG Active and Free Walk orthoses differ by
their design and functionality. While the E-MAG Active
functions electronically and independently from the
ankle joint, the Free Walk system is controlled purely
mechanically with the ankle joint correlating with the
knee joint.
Due to these differences there is the possibility of
fitting different patient groups.
Generally described, the knee-ankle-foot orthosis
(KAFO), into which the E-MAG Active is integrated, is
the fitting that comes into question for patients who:
1. have strong deviations in the frontal and sagittal
plane (knee joint and ankle joint); and/or
2. have a very atrophic, bony leg with little soft tissue
covering; and/or
3. have a considerably reduced leg (more than 5 cm);
and/or
4. require a dorsal stop in the ankle joint to get into
knee joint extension;
5. have a stiff ankle;
6. or require a strong dorsiflexion function.
1. have no or only minor deviations in the leg axis;

and
2. have a stable yet flexible ankle joint (range of
motion of at least 10); and
3. do not require large support surfaces in the
orthosis.
For detailed differentiation regarding the indication,
please see the information on pages 10.
Typical patients who can be fitted with a Free Walk

orthosis are patients who lost the control of their
muscles caused by traumatic influence, but who
have not suffered from other stronger lesions on the
extremity (e.g. condition after incomplete paraplegia).
These are patients who:

Therapeutic Benefit
The E-MAG Active and Free Walk orthoses were developed for patients who, due to a partial paralysis or a
complete failure of the knee extensors, are unable to stabilize their knee without compensatory measures.
For example, knee joints are often stabilized through hyperextension achieved by compensatory movement of the
gluteal muscles (when the foot touches the ground, the hip extension leads to a knee extension).
As a result, severe ligament instabilities and arthrotic symptoms in the knee joint will develop over time.
The orthoses can help correct these unphysiological movements, allowing patients to regain a natural gait as
much as possible.
The orthoses also offer many therapeutic benefits for paralyzed patients: Prevention of contractures and
immobilization-related joint damage. Reduction of muscular atrophy. Maintenance of cardiovascular efficiency
for daily activities. With diseases affecting the central nervous system, the orthoses also stimulate unaffected
areas of the brain to take over functions (motor relearning, cortical reorganization). That is, in a nutshell, how the
orthoses support the social and professional (re-) integration of the patient.
Medical Indications for Consideration

Treatment with stance control orthoses is indicated for pareses or paralyses of muscles and muscle groups of
the lower extremities. These may develop within the scope of the following basic diseases:
Central nervous system disorders
Condition following a stroke
Muscle diseases and conditions (myopathies)
Condition following brain tumours
Progressive muscular dystrophy
Condition following serious craniocerebral

trauma (CCT)
Other myopathies (also in the context of other basic

diseases such as Cushings myopathy)
Condition following encephalitis/brain abscesses
Condition following polymyositis/dermatomyositis
Multiple sclerosis
Ataxia in the context of diseases involving the

cerebellum (sporadic delayed atrophy of the
cerebellar cortex, inherited cerebellar ataxia)
Spinal cord diseases
Condition after spinal cord injury
(e.g., incomplete paraplegia)
Incomplete hemispinal cord syndrome

(Brown-Squard Syndrome)
Condition following spinal cord tumours and

spinal meninges tumours
Condition following transverse myelitis,
abscesses
Progressive spastic spinal paralysis
(Erb-Charcot-Strmpell)
Myatrophic lateral sclerosis
Diseases affecting the peripheral nervous

system
Radicular syndromes (e.g., condition following
hernia of the intervertebral disk, radiculitis and
poly(neuro)radiculitis, Guillain-Barr Syndrome)
Condition following lesions of the lumbar and
sacral plexuses
Peripheral nerve lesions (e.g., femoral nerve,
sciatic nerve, tibial nerve, obturator nerve,
superior and inferior gluteal nerves)
Polyneuropathy (e.g., asymmetrical diabetic
polyneuropathy, alcoholic neuropathy,
parainfectious and paraneoplastic
polyneuropathy)
Progressive spinal muscular atrophy
Condition following acute poliomyelitis

Post-polio syndrome
Degenerative diseases
(e.g., spinal canal stenosis, stenosis of the
intervertebral foramina, spondylolisthesis)
Abnormalities of the spinal cord
(e.g., vertebral arch damage with
spondylolisthesis, spina bifida aperta,
meningocele, myelomeningocele)
Funicular myelosis
Syringomyelia
Neural muscular atrophy
Anterior spinal artery syndrome

Biomechanics of the Normal Gait
The gait cycle is comprised of a stance phase and a swing phase.
The stance phase begins when the heel touches the ground and ends with the toe-off from the ground. The
swing phase begins from the toe-off and ends at the next heel contact.
The stance phase begins as soon as the heel

touches the ground. At heel strike, the knee is
controlled by the thigh and lower leg muscles.
After the terminal stance phase, the lifting of the toes

from the groundthe pre-swing phaseinitiates the
swing phase.
In the mid-stance phase, the thigh and lower leg

muscles stabilize the leg up to the end-stance phase.
During this last phase, the gait cycle is brought to a
completion exclusively by the lower leg muscles.
The initial swing phase is controlled by the hip

flexors, the knee extensors and the anterior lower leg
muscles. During transition to the mid-swing phase,
knee flexion is no longer needed to bring the leg with
its pendulum mass into the terminal swing phase.
The terminal swing phase ends directly at initial heel
contact, where the entire chain of muscles is needed
to stabilize the knee joint.
When the leg starts to bear weight, the knee is

stabilized by the extensor muscles of the thigh.
In the normal gait, the thigh extensor muscles have

an important supporting function during the stance
phase. If this supporting function is missing or
significantly weakened, the normal stance phase is
disturbed.
Initial stance phase

Heel strike of the
right foot

Mid-stance phase The standing

leg bears the weight
Mid-stance phase
This pre-swing phase utilizes primarily the pretibial

muscles and hip flexors.
The swing phase as such is not very much

affected by knee extensor deficits. Consequently,
conventional orthoses that promote stance phase
stabilization, and that are therefore locked, are too
immobilizing during the swing phase.
Terminal stance
phase of the
right leg Heel
strike of the left
foot
Pre-swing phase
The leg is unloaded,
transition to swing
phase
Swing phase of the right leg
Gait Cycle with Stance Control

Knee Joint Systems
In contrast to the gait cycle of a healthy person, the
knee joint of patients with lacking function of the
knee stabilizing muscles must be stabilized by an
orthosis.
The stance control knee joint systems from Otto
Bock provide stability only in the phase where it is
needed. The swing phase is not compromised.
Between heel contact and toe-off, i.e. when the foot
bears weight on the ground, the joints secure the
knee joint and support the knee stabilizing muscles.
Gait cycle with E-MAG Active
Heel strike with

locked knee joint
The leg fitted with the E-MAG Active

orthosis assumes weight bearing, the
knee joint is locked
During the entire stance phase, the orthoses remain

locked.
The orthotic joint is then released between the
terminal stance phase and the pre-swing phase,
allowing the patients knee joint to move freely during
the swing phase.
This provides the patient a degree of mobility that is
nearly comparable with the gait of a healthy person.
Studies have shown that, in comparison with a
locked orthosis, the E-MAG Active and Free Walk
orthoses offer considerable advantages with regard
to energy expenditure, walking speed and reduction
of the strain on the contralateral side.
Mid-stance phase
with locked knee
joint
Heel strike of the

left foot
The body moves before the foot,

complete extension of the knee
joint when the toes are lifted from
the ground, released lock
Pre-swing phase the leg

is unloaded, the leg fitted
with the orthosis with E-MAG
Active can swing through with
released lock
Mid-stance phase
with locked knee
joint
Heel strike of the

left foot
The body moves before the foot,

complete extension of the knee
joint when the toes are lifted
from the ground (dorsiflexion),
released lock
Pre-swing phase the leg is

unloaded, the leg fitted with
the Free Walk orthosis can
swing through with released
lock
Gait cycle with Free Walk
Heel strike with

locked knee joint
The leg fitted with the Free Walk orthosis

assumes weight bearing, the knee joint
is locked

Prerequisites for the Application and Differentiation of the
KAFO with E-MAG Active and the Free Walk Orthosis
Muscle strength required:
Muscle strength of the hip or knee extensors is
required to initiate the active knee joint extension that
releases the orthosis in the terminal stance phase
and leads it into pre-swing phase. If neither hip
nor knee extensor strength are present, a passive
hyperextension of the knee joint may also suffice.
At the end of the stance phase, an active hip or knee

flexor function is also required to launch the swing
phase.
Before the initial heel contact, the knee joint

extension must be actively initiated to cause the
orthotic knee joint to lock automatically. If this is not
possible, a compensatory hip movement can fulfil
the task. The pendulum effect caused by the hip
movement may suffice to fully extend the knee joint.
For assessment of a patients suitability and for
selection and differentiation of the joint systems, the
patients muscle strength and mobility of movement
are measured.
Muscle strength assessment:

0= no visible and/or palpable muscle contraction
1= visible and/or palpable muscle contraction
2= distinct muscle contraction, complete movement under best possible bearing of own weight is fully possible
3= complete movement in the range within which the muscle works against gravity
4= maintaining of test position against low to medium pressure
5= maintaining of test position against maximum pressure
Testing Muscle Strength

Knee extension
The patient supports her/himself on the edge of
the bench and tries to extend the to be tested leg
as much as possible. The tester fixes the patients
thigh with her/his proximal hand while, with the other
hand, pressing the tip of the extended lower leg in
the direction of the flexion.
Test below muscle strength grade 3 with the patient
lying on her/his side in order to equalize gravity.
Knee extension strength

10
Hip extension
The patient tries to lift her/his flexed leg off the
bench. With her/his proximal hand, the tester
palpates the muscle contraction in the gluteal area
and, with her/his distal hand, exerts pressure in the
flexion direction on the rear side of the thigh.

Hip extension strength

Knee flexion
The patient tries to flex the heel towards the
buttocks. The tester exerts pressure in the extension
direction on the flexed leg.
Knee flexion strength

Hip flexion
The patient is asked to lift her/his thigh with the knee
flexed towards her/his shoulder on the same side. At
the end of the movement, the tester exerts pressure
in the extension direction on the ventral side of the
thigh.
Hip flexion strength

11

Dorsal extension
The patient is asked to pull the back of her/his foot
up and inwards (dorsal extension and supination). At
the end of the movement, the tester exerts pressure
in the plantar flexion direction.
Dorsal extension muscle strength test
Dorsal extension muscle strength test

The tester checks the maximum passive extension
ability of the knee joint.
Knee joint hyperextension test
The following muscle strengths are required for the indication of stance control systems:

12
Muscle strength of hip extensors 3-5, or

Muscle strength of knee extensors 3-5, or
Passive hyperextension in the knee joint
Muscle strength of hip flexors 3-5, or
Compensatory hip movements
Required Mobility
To be able to optimally use the E-MAG Active or Free Walk orthosis, certain conditions in terms of mobility must
also be met. Should a patient not meet these conditions, the therapist or physician can assess whether the
patient could possibly meet the prerequisites upon completion of a therapy.
E-MAG Active
Knee joint extension, no flexion contracture above 15

(may be influenceable by dorsal stop) in the ankle joint
No hip flexion contracture

Also without ankle motion
No uncontrollable spasms
Free Walk
Ankle joint mobility
Test for hip flexion contracture
Mobility of the ankle joint, at least 10

Knee joint extension, no flexion contracture above 10
Valgus/varus deviations in the ankle joint max. 10
(not shown)
Valgus/varus deviations in the knee joint max.10
No hip flexion contracture
Sufficient support from the contralateral leg
Leg length discrepancy max. 7cm (only with stable ankle
joint)
No uncontrollable spasms
Flexion contracture in the knee joint
Valgus/varus deviations
in the knee joint
13

Leg length discrepancy
Increasing Muscle Strength

If the prerequisites described above are not entirely met, certain weaknesses can be improved with a therapy for
increasing strength and mobility. Use of a stance control orthosis is then possible at a later point in time.
Ideally, testers should provide patients with a home programme to complement the therapeutic measures.
Strengthening the knee joint extensors

Recommended exercises are so-called uni- or bilateral leg patterns from the PNF technique (Proprioceptive
Neuromuscular Facilitation), shown here in sitting position.
14
Strengthening the hip extensors und hip flexors

To facilitate hip extension and abduction, the leg patterns can also be realized with the patient lying on her/his
side with extended or flexed knee joint as well as in quadruped position.
Increasing Mobility
To improve mobility, physiotherapeutic techniques of manual therapy are suitable (here: passive joint mobilization
or muscle stretching techniques, depending on the diagnostic findings).
If muscle contractures are the cause of a hypomobility, muscle stretching techniques are recommended to
increase the range of motion (Fig. 1 - 4).
Increasing muscle mobility in the knee, ankle and foot joints.
15

Increasing muscle mobility in the knee joint and hip joint
Increasing Arthrogenous Mobility in the Foot, Knee, and Hip Joints

If joint capsules and/or ligaments impede the required mobility in the extremities, passive joint mobilization
techniques are recommended.
16
Exercises to Increase Muscle Strength and Mobility at Home

In addition to the exercises carried out with a therapist, the patient should do exercises at home to ensure a
lasting effect.
The following are some mobility increasing exercises which patients can easily do at home. The more often
the patient can do strengthening and mobilizing exercises, the sooner she/he will be able to walk safely and
physiologically with a stance control orthosis.
Please note: The measures shown here serve as a rough guideline only and must be adapted to the individual
patient.
Strengthening of the knee joint extension using a

therapy band. The non-affected leg should support
the movement.
ATTENTION:
The therapy can only be carried out if the physician/therapist has taken all
contraindications for the physiotherapeutic treatment into consideration!
17

Strengthening of the hip extension using a therapy

band.
Strengthening of the hip extension and knee joint

encompassing muscles (bridging). By changing the
knee angle, different muscle groups in the knee joint
and hip joint are strained to a different extent.
Strengthening of the hip encompassing muscles

(here: abductors).
18
Self-stretching of the calf muscles to improve

dorsal extension in the upper ankle joint (autostretching).
Auto-stretching of the hip flexors and knee extensors to improve hip extension.
19

Handling of the
Orthosis and First
Exercises
Applying the Free Walk Orthosis
The open shape of the Free Walk orthosis
makes it very easy and safe to apply.
It is crucial that the orthosis has the same
fitting position on the body at all times. This is
ensured by the pre-set closures that can be
closed and opened with a quick-lock system.
The open shape of the orthosis with
frontal pads in the thigh area allows for a
comfortable and safe application while the
patient is sitting.
The flexible foot stirrup facilitates the
application. It determines the correct fit of the
orthosis on the knee pivot point and controls
the knee joint lock.
Applying a Knee-Ankle-Foot
Orthosis with E-MAG Active Joint
System
Due to the different design options, it strongly
depends on the patients demands and
requirements how to apply the orthosis.
Important for the patient is that he can unlock
the joint system by pressing the release button
(Fig. 2) and that the E-MAG Active can then
be flexed.
20
Standing up and Locking the

The first exercisesto take place under the supervision of the therapist or orthotistare standing up, locking,
releasing, and sitting down.
These fundamental exercises serve to develop a feeling for the locking function of the orthosis and will facilitate
the release when making the first steps.
1 Standing up
Support yourself with both hands when standing up. Move the contralateral leg more forward to achieve
increased stability.
Stand up, place the heel of the fitted leg before the standing leg, and move the thigh to the rear to achieve knee
joint extension. After the orthosis has locked, try to stand evenly on both legs with the therapists assistance.
21

2a Sitting down with the Free Walk orthosis
Two different ways of sitting down can be practiced in daily life.

A: A button located directly on the knee joint is used to mechanically release the knee joint lock. This method
is particularly safe and is appropriate for situations in which the patient has to concentrate on the seat surface.
By bending her/his upper body forward, the knee is easily extended. With the arm of the contralateral side, the
patient supports her/himself on the armrest (or car door, etc.). With the hand on the side of the orthotic fitting,
the patient can then unlock the knee joint by pressing the button on the knee joint.
B: Dynamic release of the knee joint lock

The patient shifts her/his weight forward onto the contralateral leg. This causes pre-tension of the knee joint and
ankle joint of the fitted leg that is in extension and dorsal extension. With a light rocking movement, the patient
can then unlock the knee joint and sit down.
All exercises should be repeated several times with the therapists assistance. A routine of these movements will
set in only after a few days. Please note that dynamic sitting down may not be appropriate or desirable for some
patients. Nevertheless, these movements have advantages in terms of safety and protection of the body.
22
2b Sitting down with E-MAG Active
With the E-MAG Active as well, two different ways for sitting down can be practiced.
A: Electro-mechanical release of the lock is possible by pressing the lower button (s. Fig. 1) on the electronic
unit of the E-MAG Active. Like with the Free Walk orthosis, this method is appropriate for situations in which
the patient has to concentrate on sitting down. Prior to releasing the knee joint, the patient must reach a knee
extending position. Some patients are able to achieve a knee extending position in normal stance already, other
patients have to generate a knee extending moment with a conscious movement.
B: Dynamic release of the knee joint lock

Like with the Free Walk orthosis, the patient must move the contralateral leg more forward to enable the orthosis in a
backward position to switch electronically so that the E-MAG Active knee joint releases in a knee extending position.
Like with the Free Walk orthosis, the movement should be practiced with the therapists assistance to enable
the patient to get accustomed to it.
23

Gait Training
Part I Exercise for attaining even weight bearing
Before the patient walks the first steps, priority should be given to correct weight bearing of the orthosis. To
prevent atypical movements during the first steps, balancing exercises should be practiced to attain the best
possible weight bearing of the supported extremity.
For verification of correct weight bearing, the L.A.S.A.R. Posture is an ideal alternative to the conventional
scales with which inaccuracies are unavoidable. With the help of the visual weight bearing line and the hand
control device, the therapist or orthotist can give patients precise instructions on how to move in order to find the
optimal weight bearing position.
The patient must then practice standing evenly

and stably on both legs. For this purpose, different
exercises can be practiced.
Stabilizing exercise: The therapist builds up a

resistance against the shoulder and/or pelvic girdle
to train a stable stance.
24
Stabilizing exercises outside the parallel bars

These exercises are to be practiced with the legs in parallel or in step position to engage various muscle groups
of the trunk and lower extremities.
The exercises also promote the sense of balance and the weight bearing of the orthosis.
25

Part II Practicing initial heel contact up to the stance phase

If possible, the exercises should be done between the parallel bars. The parallel bars give patients an increased
sense of security, allowing them to better concentrate on the exercises. The individual step cycles should be
repeated several times independently from each other until the patient has attained a certain routine of the
movement.
The first exercise teaches patients to place trust in the function of the orthosis in the stance phase. The patient
supports her/himself with both hands on the parallel bars (depending on the initial constitution) and swings the
leg with locked orthosis from the parallel stance position to the terminal swing phase using either the residual
functions of the hip flexors or a tilt movement of the pelvis.
What follows is the initial heel contact with direct transition to weight bearing (Fig. 1). Upon weight bearing, the
patient shall try to completely unload the contralateral leg (Fig. 2). Thereafter, the patient practices the transition
from the mid-stance phase to the terminal stance phase to unlock the orthosis (Fig. 3).
Initial contact (exercise begins with

both legs in parallel position)
Ball contact transition to weight

bearing
Terminal stance phase (lock release)
At the beginning of the exercise, the therapist should

guide the affected leg during the swing phase to
provide the patient with a feeling for the correct step
length (Fig. 4).
Practicing the pre-swing phase of the affected side
26
Part III Exercise for practicing the lock release function for the swing phase with
the Free Walk orthosis
The swing phase is a critical aspect in the use of the Free Walk orthosis. While instrumental for promoting the
patients mobility and activity, it must also be well mastered and understood by the patient to guarantee a secure
functioning.
Wrong movements can cause the orthosis to function improperly. When initiating the pre-swing phase as well as
at first heel contact, the right movements must be made so that the orthosis functions properly.
During the transition from the terminal stance phase to the pre-swing phase, the orthosis is released for the
swing phase. This can only take place with an unloaded knee joint lock and sufficient dorsal extension in the
orthotic ankle joint. The knee joint lock is unloaded through knee joint extension. The latter is achieved either
through sufficient muscle strength of the hip or knee extensors or through knee joint hyperextension.
Sufficient dorsal extension is achieved by a sufficiently large step.
27

Part III Exercise for practicing the lock release function for the swing phase with a
KAFO with E-MAG Active joint system
With the E-MAG Active, initiation of the swing phase as well is of fundamental importance. Safety and proper
operation of the orthosis depend on the design and fit of the orthosis, but also on the patients understanding.
He or she must understand the function and must be physiologically able to control the orthosis.
Wrong movements can cause the orthosis to function improperly. During the transition from the terminal stance
phase to the swing phase, the orthosis is released for the swing phase. With the E-MAG Active as well, this
can only take place with an unloaded knee joint lock, i.e. extension of the orthotic knee joint.
Dorsal extension in the ankle joint is not required. Knee joint extension can be influenced by the step
length as well as by the design (e.g. adjustable dorsal stop).
28
Part IV Practicing a double step with parallel bars and on a tread mill
After practicing the individual step cycles, the double step is trained between parallel bars. To increase the
degree of difficulty, the exercise can be modified by practicing outside the parallel bars, with only one hand
supported on a bar and the other hand using a forearm crutch (not shown).
The distance that can be covered between parallel bars is relatively short as the patient is obliged to turn around
repeatedly. It is therefore advisable to use a tread mill as a training device.
On a tread mill, speed and thus step length can be influenced. The patient learns the correct movement with the
orthosis through repeated, uninterrupted gait cycles.
The highly repetitive character of tread mill training contributes considerably to automatizing the movements.
29

Daily Life Activities with stance control orthoses
To train safe and stable backward and sideward walking, different exercises can be practiced. It is important
that the patient does not unlock the knee joint when walking backwards. When the patient steps backwards
with the fitted leg, the knee joint will be extended concurrently with a dorsal extension of the ankle joint, or the
knee joint will be unlocked by the step backwards.
When walking sidewards, the patient should take care to place the fitted leg slightly before the contralateral leg
to ensure that she/he can always step safely with the loaded knee joint.
Uphill/downhill ramps
A trained patient can make effective use of specific advantages of the orthoses when walking on ramps. For
example, when walking up ramps, the orthosis is more easily unlocked, allowing the patient to swing her/his leg
through freely and step on it safely.
30
Walking down ramps is slightly more difficult for the patient at the beginning, since she/he must fully rely on the
orthosis. The patient must lean on the fitted leg with her/his full body weight in order to minimize the required
compensatory movements. The therapist should practice this with the patient.
Walking up and down steps

Walking up and down steps should only be done with a locked orthosis. Always walk up with the contralateral
leg first and walk down with the fitted leg first!
Uneven ground
Walking on uneven ground is very important in daily life. A path with coarse pebbles is well suited for practicing
walking on uneven ground.
It is important here that the patient feels how safely his orthosis works if she/he uses it correctly.
31

Light sports activities
A trained user of such orthoses will have no problem
taking up light sports and leisure activities.
Especially uniform movements such as cycling
can be easily acquired by the patient. Cycling
32
on a training device is particularly well suited for

improving the patients fitness. If approved by the
physician, other sports such as golf are also well
suited for the patients.
Frequently Asked Questions Regarding the Function

of the Free Walk Orthosis
Why does the orthosis fail to unlock?
Is knee extension fully achieved at toe-off?
Is the patient able to reach the knee extension stop of the orthosis?
Is the orthotic knee joint behind the load line?
Does the ankle joint have sufficient stability?
Has the cable shifted or is it broken?
Why does the orthosis fail to lock?

Does the patient reach the extension stop of the orthotic knee joint before initial heel contact?
Does the patient have sufficient muscles or sufficient hip movement to swing the leg into extension?
Why are some components wearing out quickly?

If the plastic loops break: Are the holder tubes correctly positioned? (Lower holder tubes should be
mounted posteriorly for patients with hyperextension of the knee joint.)
How often should the orthosis be serviced?

The orthosis should be examined for wear by the responsible orthotist at least every 12 months.
All wearing parts such as plastic bearings, dorsiflexion assist rings made of PU, cables, as well as
pads and closures can be replaced.
33

Frequently Asked Questions Regarding the Function
of the KAFO with E-MAG Active Joint System
Why does the orthosis fail to unlock?
Does the patient achieve full knee extension of the orthotic knee joint prior to toe-off?
Is the patient able to reach the knee extension stop of the orthosis?
Is the alignment of the orthosis correct, i.e. does the orthotic knee joint get behind the load line?
Is the dorsal stop in the ankle joint sufficient?
If no ankle joint is present: is the alignment of the foot in relation to the lower leg or knee joint correct?
Is the foot sole too flexible and cannot be used to affect knee extension?
Are the electronic unit, the knee joint, and the cables in good order?
Is the battery in good order and charged?
Why does the orthosis fail to lock?

Does the patient reach the extension stop of the orthotic knee joint before initial heel contact?
Is the patient able at all to safely get into extension with his/her remaining muscles or through hip
movement?
Is the alignment of the orthosis correct?
Why are some components wearing out quickly?

In case of early wear of the plastic bearings: are the joints parallel to each other?
Is the alignment of the orthosis correct?
In case of humidity or oxidation in the electronic components: have the components been installed
correctly?
How often should the orthosis be serviced?

According to the instructions for use, the orthosis is to be serviced every 6 months following a
maintenance schedule.
34
Notes on the fitting
35
2008 Otto Bock HealthCare LP. 08081522.4 12/08
USA 800.328.4058 Fax 800.962.2549 www.ottobockus.com

Therapeutic Gait Training

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Therapeutic Gait Training

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Therapeutic Application and

| Information for orthotists and therapists |

E-MAG Active and Free Walk

However, the best intelligent leg orthosis is worthless

It is with great pleasure that I present this training

Dr. med. Axel Ruetz

E-MAG Active and Free Walk

Biomechanics of the Normal Gait

Gait Cyle with the E-MAG Active and Free Walk

Prerequisites and Targeted Therapy for the Application

Handling of the Orthosis and First Exercises

Specific Gait Training with Stance Control Orthoses

Daily Life Activities

Frequently Asked Questions

1. have no or only minor deviations in the leg axis;

Typical patients who can be fitted with a Free Walk

E-MAG Active and Free Walk

Medical Indications for Consideration

Muscle diseases and conditions (myopathies)

Condition following brain tumours

Progressive muscular dystrophy

Condition following serious craniocerebral

Other myopathies (also in the context of other basic

Condition following encephalitis/brain abscesses

Condition following polymyositis/dermatomyositis

Ataxia in the context of diseases involving the

Incomplete hemispinal cord syndrome

Condition following spinal cord tumours and

Diseases affecting the peripheral nervous

Progressive spinal muscular atrophy

Condition following acute poliomyelitis

Neural muscular atrophy

Anterior spinal artery syndrome

E-MAG Active and Free Walk

The stance phase begins as soon as the heel

After the terminal stance phase, the lifting of the toes

In the mid-stance phase, the thigh and lower leg

The initial swing phase is controlled by the hip

When the leg starts to bear weight, the knee is

In the normal gait, the thigh extensor muscles have

Initial stance phase

Mid-stance phase The standing

This pre-swing phase utilizes primarily the pretibial

The swing phase as such is not very much

Swing phase of the right leg

Gait Cycle with Stance Control

Gait cycle with E-MAG Active

Heel strike with

The leg fitted with the E-MAG Active

During the entire stance phase, the orthoses remain

Heel strike of the

The body moves before the foot,

Pre-swing phase the leg

Heel strike of the

The body moves before the foot,

Pre-swing phase the leg is

Gait cycle with Free Walk

Heel strike with

The leg fitted with the Free Walk orthosis

E-MAG Active and Free Walk

At the end of the stance phase, an active hip or knee

Before the initial heel contact, the knee joint

Muscle strength assessment: