The review, conducted by Khosro Rezaee, Somayeh Abdollahi-Holagh and Mojtaba Ansari of the Department of Biomedical Engineering at Meybod University in Iran, set out to answer a deceptively simple question: which modified-AFO technologies have actually been investigated in neurological rehabilitation, and what kinds of clinical, biomechanical, patient-reported, safety and implementation outcomes does the existing evidence cover? To answer it, the team searched six major databases, including PubMed/MEDLINE, Scopus, Web of Science Core Collection, Embase, the Cochrane Library and IEEE Xplore, capturing peer-reviewed evidence published between January 2018 and April 2026. That window deliberately targeted the most recent era of orthotic innovation, when digital fabrication and wearable sensing began transforming the field.

Methodologically, the review is a scoping exercise rather than a traditional meta-analysis, and the authors are transparent about its boundaries. Eligible primary studies and review-level sources were charted according to population, AFO technology, study design, comparator, outcome domain and implementation characteristics, then synthesized narratively. To avoid inflating the apparent size of the evidence base, primary and review-level sources were analyzed separately, reducing double counting of the same underlying trials. Importantly, the authors did not perform a formal risk-of-bias or certainty-of-evidence assessment, which means the map describes where evidence exists rather than how strong that evidence is, a distinction that matters when interpreting the findings.

After screening, 44 eligible evidence sources made the final map: 29 primary or primary-like studies and 15 review-level publications. The distribution across neurological populations is striking. Stroke dominated the literature, accounting for 14 of the 44 sources, followed by cerebral palsy with 12 and multiple sclerosis with 5. This concentration reflects both the prevalence of these conditions and the characteristic gait impairments they produce. In stroke survivors, hemiparesis often leaves the ankle unable to dorsiflex adequately, producing the classic foot-drop pattern that AFOs are designed to correct. In cerebral palsy, spasticity and contractures create complex, highly individualized ankle-foot deformities, while in multiple sclerosis, fluctuating fatigue and weakness demand devices that can adapt to changing function across the day.

The outcome measures reported across these studies reveal both the strengths and blind spots of the field. Gait speed was the most frequently represented outcome, appearing in 29 of the 44 sources, with ankle kinematics close behind at 26 and step length or symmetry at 25. These are the bread-and-butter metrics of gait laboratories: fast, objective and readily captured with motion-capture systems, instrumented walkways and wearable inertial sensors. Yet the authors found a sharp drop-off when it came to outcomes that matter most to patients in daily life. Quality of life or participation appeared in only 8 sources, safety or adverse-event reporting in just 7, and cost or accessibility in a mere 5. In other words, the field has become exceptionally good at measuring how people walk in a lab while remaining comparatively silent about whether the devices improve lives, cause harm, or are affordable and available to those who need them.

The technology map itself is equally revealing. Conventional and articulated AFOs, the workhorses of clinical practice, enjoyed the broadest clinical representation across the literature. These passive mechanical devices control ankle position through material stiffness and geometric design, and decades of clinical familiarity have built a substantial evidence base around them. Carbon-fiber dynamic AFOs, which store and release energy during gait much like a spring, have also accumulated meaningful clinical data, particularly for foot drop in stroke and multiple sclerosis. By contrast, the newest categories, 3D-printed and customized orthoses, smart or sensor-based devices, and active-assistance systems, were represented by more heterogeneous evidence that was often short-term or oriented toward technical validation rather than clinical outcomes.

This heterogeneity is not surprising given the engineering challenges involved. Additive manufacturing allows orthotists to produce braces tailored to a patient’s exact anatomy, with locally tuned stiffness zones that no off-the-shelf device can match, but the design space is enormous and standardized design guidelines are still emerging. Smart AFOs embed inertial measurement units, pressure sensors or electromyography electrodes to monitor gait in real time, opening the door to remote clinical monitoring and closed-loop control, yet most published studies remain proof-of-concept demonstrations with small samples and brief follow-up. Active-assistance orthoses go further, using actuators to deliver dorsiflexion assistance or plantarflexion control, and hybrid AFO-functional electrical stimulation systems combine mechanical support with timed electrical stimulation of the peroneal nerve. These approaches are technologically dazzling, but the review shows that their clinical evidence remains fragmented and immature compared with conventional devices.

Perhaps the most consequential conclusion of the review is what it does not find. The authors explicitly caution against reading the evidence map as a hierarchy of device effectiveness. Instead, they argue, the findings support individualized interpretation of AFO characteristics: the right device depends on the patient’s specific impairment pattern, goals, environment and resources, not on a universal ranking of technologies. A sophisticated powered orthosis may be transformative for one patient and impractical for another, while a simple articulated brace may deliver the best long-term value for many. This message pushes back against a common temptation in rehabilitation engineering, where novelty is often conflated with superiority, and it underscores the need for comparative studies that pit new technologies against established ones rather than against no-treatment baselines alone.

The review also lays out a clear agenda for the field’s next decade. The authors call for comparative evaluation across device categories, standardized technical reporting so that devices can actually be replicated and compared, and longer-term real-world follow-up that extends beyond the laboratory and the acute study period. They emphasize consistent assessment of patient-centered outcomes, adherence, safety, cost and accessibility, the domains the map shows to be chronically underrepresented. Without such data, clinicians and health systems cannot make informed decisions about which technologies deserve investment, and patients cannot be countheled realistically about what a given device will mean for their independence, comfort and finances. The evidence map thus functions as both a snapshot and a challenge: it shows a field that has successfully spanned the spectrum from passive mechanical control to digitally customized, sensor-integrated and actively assisted systems, while exposing exactly where the scientific foundation is thinnest.

For patients, clinicians and device developers alike, the message is one of cautious optimism. The engineering revolution in ankle-foot orthotics is real, and the tools now exist to personalize, sense and actively assist gait in ways unimaginable a generation ago. But turning that engineering promise into reliable clinical benefit will require the kind of rigorous, patient-centered, long-term comparative research that this review identifies as missing. As wearable technology continues its rapid advance, the evidence map offers researchers a compass: the destination is not more gadgets, but better lives, measured not only in meters per second on a gait lab walkway, but in participation, safety, affordability and the quiet confidence of a steadier step.

Subject of Research: Modified ankle–foot orthosis technologies in neurological rehabilitation, evaluated through a systematic scoping review and evidence map

Article Title: Modified ankle–foot orthoses in neurological rehabilitation: a systematic scoping review and evidence map

Article References: Rezaee, K., Abdollahi-Holagh, S., & Ansari, M. (2026). Modified ankle–foot orthoses in neurological rehabilitation: a systematic scoping review and evidence map. BioMedical Engineering OnLine. https://doi.org/10.1186/s12938-026-01630-6

Image Credits: AI Generated

DOI: 10.1186/s12938-026-01630-6

Keywords: ankle-foot orthosis, neurological rehabilitation, stroke, cerebral palsy, multiple sclerosis, 3D printing, smart orthosis, functional electrical stimulation, gait analysis, evidence mapping, wearable technology, biomedical engineering

Spinal cord injuries and diseases severely impact the quality of life for those affected, rendering everyday tasks increasingly difficult. Traditional exoskeletons designed to assist with grasping often fail to transition from laboratory environments to real-world applications, leading researchers to probe the reasons behind this gap. Dr. Derek Wolf, the principal investigator of the study, candidly points out that while many promising devices exist, they frequently do not gain traction in everyday life due to a myriad of factors ranging from usability issues to a disconnect between designers and end users.

One major objective of this research is to elevate the understanding of user needs throughout the design and development process. By engaging with individuals who have lived experiences of spinal cord injuries, the team aspires to create a solution that resonates on a personal level, ultimately enhancing user acceptance and efficacy. Dr. Wolf articulates his vision of an inclusive research approach, emphasizing that to bridge the gap between innovative engineering solutions and tangible benefits for users, involving the end users from the inception of the design is paramount.

The project aims to innovate beyond traditional robotics by integrating FES, a technique that employs electrical currents to elicit muscle contractions in paralyzed limbs. Dr. Wolf asserts that merely placing an exoskeleton over a user’s hand may not be sufficient; understanding how to utilize existing muscle capabilities can significantly contribute to the device’s effectiveness. This hybrid approach intends to exploit muscle contractions facilitated by FES while ensuring that the exoskeleton amplifies these movements rather than redundantly replicating them.

The integration of FES introduces not only technical advantages but also the potential for improved motor control and task efficiency. Effective coordination between the FES and exoskeleton could lead to a smoother, more natural grasp, permitting users to engage more freely in everyday activities. Dr. Wolf’s expertise in FES provides a foundation for exploring how electrical stimulation and passive mechanical support can work in concert, overcoming some of the efficiency gaps present in existing assistive technologies.

However, challenges abound in creating an intuitive user interface that extends beyond simple functionality. This project highlights the necessity of simplicity and accessibility in medical devices, particularly for individuals with varying levels of physical ability. Strategies must be developed to facilitate ease of use in grappling with complex designs while ensuring that the final product meets the diverse needs of its users. The interplay between individual requirements and collective usability underscores the difficulty in conceptualizing devices that can cater to both personal and broad spectrum applications.

As the project unfolds, advocates Sarah Elam and Dave Reed have joined the research team as paid advisors who will provide invaluable input throughout the two-year duration. Their expertise shines a light on the real challenges faced by individuals living with disabilities, serving as a reminder that empathetic design is critical in creating meaningful technology. Elam, who has multiple sclerosis and is a quadriplegic, recognizes the importance of being an active and engaged participant in the engineering process, validating the principle that skillfully integrating user feedback can transform the trajectory of device evolution.

The initiative provides not only technological advancements but also a platform for personal empowerment and community engagement. Reed, who has restored partial movement after a spinal cord injury, sees the project as an opportunity to contribute to the greater good and expand his knowledge about assistive technologies. Their involvement underscores a trend toward democratizing scientific exploration, with individuals impacted by disabilities taking an active role in shaping the devices designed for their benefit.

The engineering team, composed of dedicated students such as Ryan Cuda, is driving the practical execution of the design process. Cuda’s commitment to translational research highlights a growing recognition among engineers of the social responsibility inherent in their work. The project’s iterative design methodology reflects a progressive approach where prototypes are continuously refined based on feedback from end users, ensuring that each version is a step closer to fulfilling the actual needs of its intended audience.

This collaborative atmosphere cultivates a sense of unity between engineers and users, a departure from traditional paradigms where engineers often operate in isolation. Cuda reflects on his motivation to work on projects with direct human impact, exhibiting a shared passion among the team to work toward a prototype that could substantially improve the assisting capabilities of future devices.

In addition to enhancing human-technology interaction, the project illustrates the potential for cross-disciplinary collaboration between mechanical engineering and health sciences. Co-investigators including medical professionals with experience in user-centered design and regulatory compliance add a necessary layer of clinical insight, ensuring that the aspirations of the engineering team align with the regulatory and practical realities of medical device development. This holistic approach engenders project stability and a broader understanding of the regulatory landscape as it pertains to product development and patient safety.

As the project progresses, the goal remains firmly rooted in creating a device that is both functional and maneuverable. Feedback cycles structured around two-month sprints promote a continuous learning environment where the design iterations are informed directly by user experiences and performance testing. This adaptive method recognizes the need for agility in the face of unforeseen challenges while maintaining a steadfast focus on the end goal: a reliable assistive device that empowers users to regain autonomy in their daily lives.

In conclusion, the University of Cincinnati’s innovative research project represents a beacon of hope for individuals with spinal cord injuries, highlighting the transformative power of collaboration between engineers, medical professionals, and end users. By integrating the insights of individuals with lived experiences into the design process, the team is poised to create a functional, intuitive assistive device capable of significantly improving the quality of life for those grappling with disabilities. This project not only exemplifies the potential for technological innovation but also underscores a broader commitment to ethical and equitable engineering that serves the diverse needs of a multifaceted community.

Subject of Research: Integration of Exoskeletons and Functional Electrical Stimulation for Hand Function Restoration
Article Title: Embracing Change: How User-Centered Design is Transforming Assistive Technology for Spinal Cord Injury
News Publication Date: October 2023
Web References: Not available
References: Not available
Image Credits: Photo/Corrie Mayer/University of Cincinnati

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