{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,6]],"date-time":"2026-04-06T21:19:48Z","timestamp":1775510388562,"version":"3.50.1"},"reference-count":46,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2023,1,4]],"date-time":"2023-01-04T00:00:00Z","timestamp":1672790400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100009619","name":"AMED","doi-asserted-by":"publisher","award":["JP18he0402255"],"award-info":[{"award-number":["JP18he0402255"]}],"id":[{"id":"10.13039\/100009619","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009619","name":"AMED","doi-asserted-by":"publisher","award":["JP18he1902005"],"award-info":[{"award-number":["JP18he1902005"]}],"id":[{"id":"10.13039\/100009619","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009619","name":"AMED","doi-asserted-by":"publisher","award":["JP21he2202005"],"award-info":[{"award-number":["JP21he2202005"]}],"id":[{"id":"10.13039\/100009619","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Genu recurvatum (knee hyperextension) is a common problem after stroke. It is important to promote the coordination between knee and ankle movements during gait; however, no study has investigated how multi-joint assistance affects genu recurvatum. We are developing a gait training technique that uses robotized knee-ankle-foot orthosis (KAFO) to assists the knee and ankle joints simultaneously. This report aimed to investigate the safety of robotized KAFO-assisted gait training (Experiment 1) and a clinical trial to treat genu recurvatum in a patient with stroke (Experiment 2). Six healthy participants and eight patients with chronic stroke participated in Experiment 1. They received robotized KAFO-assisted gait training for one or 10 sessions. One patient with chronic stroke participated in Experiment 2 to investigate the effect of robotized KAFO-assisted gait training on genu recurvatum. The patient received the training for 30 min\/day for nine days. The robot consisted of KAFO and an attached actuator of four pneumatic artificial muscles. The assistance parameters were adjusted by therapists to prevent genu recurvatum during gait. In Experiment 2, we evaluated the knee joint angle during overground gait, Fugl-Meyer Assessment of lower extremity (FMA-LE), modified Ashworth scale (MAS), Gait Assessment and Intervention Tool (G.A.I.T.), 10-m gait speed test, and 6-min walk test (6MWT) before and after the intervention without the robot. All participants completed the training in both experiments safely. In Experiment 2, genu recurvatum, FMA-LE, MAS, G.A.I.T., and 6MWT improved after robotized KAFO-assisted gait training. The results indicated that the multi-joint assistance robot may be effective for genu recurvatum after stroke.<\/jats:p>","DOI":"10.3390\/jcm12020415","type":"journal-article","created":{"date-parts":[[2023,1,5]],"date-time":"2023-01-05T02:00:57Z","timestamp":1672884057000},"page":"415","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Robotized Knee-Ankle-Foot Orthosis-Assisted Gait Training on Genu Recurvatum during Gait in Patients with Chronic Stroke: A Feasibility Study and Case Report"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7807-1189","authenticated-orcid":false,"given":"Yoko","family":"Takahashi","sequence":"first","affiliation":[{"name":"Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan"},{"name":"Department of Brain Robot Interface, Advanced Telecommunications Research Institute International, Kyoto 619-0288, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9154-8703","authenticated-orcid":false,"given":"Kohsuke","family":"Okada","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1055-5080","authenticated-orcid":false,"given":"Tomoyuki","family":"Noda","sequence":"additional","affiliation":[{"name":"Department of Brain Robot Interface, Advanced Telecommunications Research Institute International, Kyoto 619-0288, Japan"},{"name":"Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tatsuya","family":"Teramae","sequence":"additional","affiliation":[{"name":"Department of Brain Robot Interface, Advanced Telecommunications Research Institute International, Kyoto 619-0288, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Takuya","family":"Nakamura","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Koshiro","family":"Haruyama","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo 113-8421, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kohei","family":"Okuyama","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kengo","family":"Tsujimoto","sequence":"additional","affiliation":[{"name":"Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo 187-8551, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9324-495X","authenticated-orcid":false,"given":"Katsuhiro","family":"Mizuno","sequence":"additional","affiliation":[{"name":"Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo 187-8551, Japan"},{"name":"Department of Rehabilitation Medicine, Tokai University School of Medicine, Kanagawa 259-1193, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jun","family":"Morimoto","sequence":"additional","affiliation":[{"name":"Department of Brain Robot Interface, Advanced Telecommunications Research Institute International, Kyoto 619-0288, Japan"},{"name":"Graduate School of Informatics, Kyoto University, Kyoto 606-8501, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6459-3325","authenticated-orcid":false,"given":"Michiyuki","family":"Kawakami","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,1,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/S0004-9514(14)60486-4","article-title":"Observation and analysis of hemiplegic gait: Stance phase","volume":"39","author":"Moseley","year":"1993","journal-title":"Aust. J. Physiother."},{"key":"ref_2","first-page":"1147","article-title":"Electrogoniometric feedback: Its effect on genu recurvatum in stroke","volume":"73","author":"Morris","year":"1992","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1093\/brain\/102.2.405","article-title":"Different types of disturbed motor control in gait of hemiparetic patients","volume":"102","author":"Knutsson","year":"1979","journal-title":"Brain"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1016\/j.jstrokecerebrovasdis.2016.01.028","article-title":"Prevalence of genu recurvatum during walking and associated knee pain in chronic hemiplegic stroke patients: A preliminary survey","volume":"25","author":"Tani","year":"2016","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.rehab.2010.01.001","article-title":"Treatment of genu recurvatum in hemiparetic adult patients: A systematic literature review","volume":"53","author":"Bleyenheuft","year":"2010","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"S381","DOI":"10.3233\/BME-151326","article-title":"Reduced knee hyperextension after wearing a robotic knee orthosis during gait training\u2014A case study","volume":"26","author":"Mao","year":"2015","journal-title":"Bio-Med. Mater. Eng."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1002\/pri.528","article-title":"The relationship of lower limb muscle strength and knee joint hyperextension during the stance phase of gait in hemiparetic stroke patients","volume":"17","author":"Cooper","year":"2012","journal-title":"Physiother. Res. Int."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1080","DOI":"10.2106\/00004623-195436050-00016","article-title":"A back-knee brace","volume":"36\u2013A","author":"Hipps","year":"1954","journal-title":"J. Bone Jt. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.clinbiomech.2012.09.007","article-title":"Effects of a knee-ankle-foot orthosis on gait biomechanical characteristics of paretic and non-paretic limbs in hemiplegic patients with genu recurvatum","volume":"28","author":"Boudarham","year":"2013","journal-title":"Clin. Biomech."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.1016\/j.pmrj.2015.04.007","article-title":"Prevention of genu recurvatum in poststroke patients using a hinged soft knee orthosis","volume":"7","author":"Portnoy","year":"2015","journal-title":"PM&R"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1097\/NPT.0000000000000137","article-title":"Control of stroke-related genu recurvatum with prolonged timing of dorsiflexor functional electrical stimulation: A case study","volume":"40","author":"Chantraine","year":"2016","journal-title":"J. Neurol. Phys. Ther."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1589\/jpts.31.865","article-title":"Effects of dorsiflexor functional electrical stimulation compared to an ankle\/foot orthosis on stroke-related genu recurvatum gait","volume":"31","author":"Bae","year":"2019","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1016\/j.gaitpost.2013.10.008","article-title":"Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study","volume":"39","author":"Gross","year":"2014","journal-title":"Gait Posture"},{"key":"ref_14","first-page":"232","article-title":"Effectiveness of prowling with proprioceptive training on knee hyperextension among stroke subjects using videographic observation-a randomised controlled trial","volume":"6","author":"Daral","year":"2018","journal-title":"Gait Posture"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1016\/j.rehab.2020.02.008","article-title":"Effects of robotic gait training after stroke: A meta-analysis","volume":"639","author":"Moucheboeuf","year":"2020","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"661815","DOI":"10.3389\/fneur.2021.661815","article-title":"The effect of robotic assisted gait training with Lokomat\u00ae on balance control after stroke: Systematic review and meta-analysis","volume":"12","author":"Baronchelli","year":"2021","journal-title":"Front. Neurol."},{"key":"ref_17","first-page":"CD006185","article-title":"Electromechanical-assisted training for walking after stroke","volume":"10","author":"Mehrholz","year":"2020","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1186\/s12984-021-00857-9","article-title":"Effect of robotic-assisted gait training on objective biomechanical measures of gait in persons post-stroke: A systematic review and meta-analysis","volume":"18","author":"Arumugam","year":"2021","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"78","DOI":"10.2340\/16501977-2505","article-title":"Feasibility and effectiveness of repetitive gait training early after stroke: A systematic review and meta-analysis","volume":"51","author":"Truijen","year":"2019","journal-title":"J. Rehabil. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1036","DOI":"10.1016\/j.jamda.2019.10.010","article-title":"Effectiveness of intervention based on end-effector gait trainer in older patients with stroke: A systematic review","volume":"21","author":"Maranesi","year":"2020","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"829","DOI":"10.2522\/ptj.20080180","article-title":"Allowing intralimb kinematic variability during locomotor training poststroke improves kinematic consistency: A subgroup analysis from a randomized","volume":"89","author":"Lewek","year":"2009","journal-title":"Phys. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Noda, T., Takai, A., Teramae, T., Hirookai, E., Hase, K., and Morimoto, J. (2018, January 21\u201325). Robotizing double\u2013bar ankle-foot orthosis. Proceedings of the 2018 IEEE International Conference on Robotics and Automation (ICRA), Brisbane, Australia.","DOI":"10.1109\/ICRA.2018.8462911"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"13","DOI":"10.2340\/1650197771331","article-title":"The post-stroke hemiplegic patient. I. A. Method for evaluation of physical performance","volume":"7","author":"Jaasko","year":"1975","journal-title":"Scand. J. Rehabil. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1093\/ptj\/67.2.206","article-title":"Interrater reliability of a modified Ashworth scale of muscle spasticity","volume":"67","author":"Bohannon","year":"1987","journal-title":"Phys. Ther."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1016\/j.jneumeth.2008.12.016","article-title":"Development and testing of the Gait Assessment and Intervention Tool (G.A.I.T.): A measure of coordinated gait components","volume":"178","author":"Daly","year":"2009","journal-title":"J. Neurosci. Methods"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (2002). ATS statement: Guidelines for the six-minute walk test. Am. J. Respir. Crit. Care Med., 166, 111\u2013117.","DOI":"10.1164\/ajrccm.166.1.at1102"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"870","DOI":"10.23736\/S1973-9087.17.04468-9","article-title":"Feasibility and safety of early lower limb robot-assisted training in sub-acute stroke patients: A pilot study","volume":"53","author":"Gandolfi","year":"2017","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.apmr.2019.09.005","article-title":"The Safety and feasibility of exoskeletal-assisted walking in acute rehabilitation after spinal cord injury","volume":"101","author":"McIntosh","year":"2020","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/1743-0003-11-92","article-title":"Gait training early after stroke with a new exoskeleton\u2014The hybrid assistive limb: A study of safety and feasibility","volume":"11","author":"Nilsson","year":"2014","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"822","DOI":"10.1055\/s-0036-1593805","article-title":"The effectiveness and safety of exoskeletons as assistive and rehabilitation devices in the treatment of neurologic gait disorders in patients with spinal cord injury: A systematic review","volume":"6","author":"Fisahn","year":"2016","journal-title":"Glob. Spine J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1080\/10790268.2019.1671076","article-title":"Safety and feasibility of exoskeleton-assisted walking during acute\/sub-acute SCI in an inpatient rehabilitation facility: A single-group preliminary study","volume":"43","author":"Delgado","year":"2020","journal-title":"J. Spinal Cord. Med."},{"key":"ref_32","first-page":"368","article-title":"Genu recurvatum: Auditory biofeedback treatment for adult patients with stroke or head injuries","volume":"3","author":"Hogue","year":"1983","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"125","DOI":"10.2340\/165019778921125130","article-title":"Biofeedback treatment of genu-recurvatum using an electrogoniometric device with an acoustic signal. One-year follow-up","volume":"21","author":"Basaglia","year":"1989","journal-title":"Scand. J. Rehabil. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"12461","DOI":"10.1038\/s41598-020-69367-3","article-title":"Neuroplastic effects of end-effector robotic gait training for hemiparetic stroke: A randomised controlled trial","volume":"10","author":"Kim","year":"2020","journal-title":"Sci. Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"770","DOI":"10.3389\/fbioe.2020.00770","article-title":"Differences in muscle synergy symmetry between subacute post-stroke patients with bioelectrically-controlled exoskeleton gait training and conventional gait training","volume":"8","author":"Tan","year":"2020","journal-title":"Front. Bioeng. Biotechnol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"105807","DOI":"10.1016\/j.jstrokecerebrovasdis.2021.105807","article-title":"Effect of robot assisted gait training on motor and walking function in patients with subacute stroke: A random controlled study","volume":"30","author":"Li","year":"2021","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"706569","DOI":"10.3389\/fnagi.2021.706569","article-title":"Efficacy of a novel exoskeletal robot for locomotor rehabilitation in stroke patients: A multi-center, non-inferiority, randomized controlled trial","volume":"13","author":"Li","year":"2021","journal-title":"Front. Aging Neurosci."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1007\/s10548-021-00825-5","article-title":"Effects of robotic neurorehabilitation on body representation in individuals with stroke: A preliminary study focusing on an EEG-based approach","volume":"34","author":"Maggio","year":"2021","journal-title":"Brain Topogr."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Oh, W., Park, C., Oh, S., and You, S.J.H. (2021). Stage 2: Who are the best candidates for robotic gait training rehabilitation in hemiparetic stroke?. J. Clin. Med., 10.","DOI":"10.3390\/jcm10235715"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1007\/s13760-020-01276-8","article-title":"Does robot-assisted gait training improve mobility, activities of daily living and quality of life in stroke? A single-blinded, randomized controlled trial","volume":"120","author":"Mustafaoglu","year":"2020","journal-title":"Acta Neurol. Belg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1093\/brain\/119.5.1737","article-title":"Spasticity and muscle contracture following stroke","volume":"119","author":"Ada","year":"1996","journal-title":"Brain"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1016\/S1474-4422(07)70193-X","article-title":"Spastic movement disorder: Impaired reflex function and altered muscle mechanics","volume":"6","author":"Dietz","year":"2007","journal-title":"Lancet Neurol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1041","DOI":"10.1152\/jn.01279.2007","article-title":"Demystifying spasticity: Reply to Dietz","volume":"99","author":"Bennett","year":"2008","journal-title":"J. Neurophysiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1007\/s00198-009-1038-3","article-title":"Compromised bone strength index in the hemiparetic distal tibia epiphysis among chronic stroke patients: The association with cardiovascular function, muscle atrophy, mobility, and spasticity","volume":"21","author":"Pang","year":"2010","journal-title":"Osteoporos. Int."},{"key":"ref_45","unstructured":"Perry, J., and Burnfield, J.M. (2010). GAIT ANALYSYS: Normal and Pathological Function, Slack Incorporated. [2nd ed.]."},{"key":"ref_46","first-page":"4859","article-title":"Changes in gait symmetry after training on a treadmill with biofeedback in chronic stroke patients: A 6-month follow-up from a randomized controlled trial","volume":"22","author":"Druzbicki","year":"2016","journal-title":"J. Pharmacol. Exp. Ther."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/2\/415\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T17:58:54Z","timestamp":1760119134000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/2\/415"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1,4]]},"references-count":46,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2023,1]]}},"alternative-id":["jcm12020415"],"URL":"https:\/\/doi.org\/10.3390\/jcm12020415","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1,4]]}}}