Byl Journal of Medical Case Reports 2012, 6:216 http://www.jmedicalcasereports.com/content/6/1/216 Page 3 of 5 Figure 1 Robotic leg orthosis. (a) Tibion Bionic Leg orthosis and (b) shoe insert with foot sensor. parameters subjectively following evaluation, with the goal of balancing the physical contributions from the patient and the RLO during therapy. The primary mode of operation is an automatic as- sist mode, in which the motorized actuator supplies forces that act against gravity based on the move- ment and biomechanics of the user. The device can provide assistance with extension (for stair ascent, stance phase, forward propulsion, and so on), con- trolled flexion (for stair descent or stand-to-sit) and free movement during the swing phase. The actuated RLO allows the user to engage his or her weaker leg more than would otherwise be possible, enabling the therapist to focus attention on patient midline posi- tioning, symmetry and weight bearing through the involved lower extremity. Participants received physical therapy using the RLO over a four-week period, at an individualized training frequency. Each training session was approximately 2 hours in length, with 1.5 hours allocated specifically for exercise. Programs were designed to require attention and repetition, and were similar for all participants, but adapted in difficulty to address the baseline ability of each participant. Each session began with a series of sit- to-stand transfers and standing squat activities. During walking, verbal and visual cues were given to focus the participant to actively use the involved limb, provide equal weight distribution through both lower extremities and attempt symmetrical steps emphasizing a ‘step through’ pattern. Depending on the participant’s ability, gait training was advanced to involve obstacle clearance, uneven terrain, community ambulation, forced speed on a treadmill, reciprocal stair climbing, sidestepping, back- wards walking and walking without the use of a cane. During active therapy, the therapist provided stand-by guarding. Patients did not receive additional therapy in the one-month period following the RLO training. The author assessed participants without the RLO at baseline, immediately following the completed course of therapy, and one month after therapy. Mobility assess- ments included the 10 meter walk test, 6 minute walk test and the Tinetti Gait Assessment [13]; balance assessments were the TUG test [14] and the FTSTS test [15]. Upon the completion of the study, all participants completed a questionnaire regarding their experience using the robotic device. All three participants safely completed task-specific mobility practice with the RLO with minimal assistance from a physical therapist. Tables 1 and 2 summarize the baseline and post-intervention values for the functional outcome assessments measured in this case series. After four weeks of training with the RLO, each participant achieved measurable and clinically significant gains in gait speed (>0.1m/s) and endurance. Step length