**3. Plantar pressure and shear analysis**

The assessment of plantar and shear pressures is of great importance for the gait health evaluation analysis, aiming to understand the effects induced in/by the body and to prevent the ulceration of the foot [40]. The pressure ulcers occur when tissue is compressed during prolonged periods of time, resulting in a wound that can infect and cause amputation, or in more severe cases, the patient's death [41]. An early identification of individuals at risk of foot ulceration (people with diabetes mellitus and peripheral neuropathy) is one of the primary means to reduce its incidence [40, 41]. Due to the poor load distribution, resulting from the reduced sensitivity of the foot, abnormally high plantar pressures occur in certain areas of the foot, and when that happens, it can lead to the growth of pressure sores in these locations [42]. The most affected areas are those with bony prominences, such as under the metatarsal bones, where the majority of plantar neuropathic ulcers occur [43]. Correct and continuous mapping of plantar pressure can prevent the occurrence of these pathologies, with the adoption of different walking habits or the use of correction equipment. On the other hand, in the case of the existence of ulcers, a redistribution of the forces imposed on the foot during walking aids healing and prevents further ulceration.

The force applied to the skin surface by a supporting structure has two components: the pressure acting normal to the surface and the shear stress acting in a tangential direction. Many authors have suggested that shear stresses have a pathogenic factor in the development of plantar ulcers [40–43]. This shear stress exists if there is sliding between two surfaces (foot and shoe), and it is closely related to friction [44]. Despite the importance of shear monitoring in assessing gait patterns, only normal pressure is widely reported. The lack of a validated and commercially available shear stress sensor is one of the main reasons why shear analysis is not as referenced as plantar pressure.

There are several solutions in the market for measuring plantar pressure, static in the form of fixed platforms, and wearable as shoes insoles. In regards of the importance of gait-related pathologies in the general population, and in the elder generation in particular, several works have been developed to improve the stateof-the-art. The literature reports the use of various technologies of plantar pressure and shear sensors, such as magneto-resistors, strain gauges, piezoelectric materials, capacitive sensors, and micro-strip antennas and coils.

As an alternative to these electronic devices, optical fiber-based sensors stand out due to their small diameter (hundreds of micrometers) and robustness, biocompatibility, high precision, electromagnetic insensitivity, as well as being electrically free at the point of measurement and owning the property of being able to multiplex several sensors in the same fiber, which allows to simultaneously monitor different parameters [45, 46].

Following such path, research studies have been carried out with FBG-based sensors used to measure not only plantar pressure but also shear parameters.

### **3.1 Plantar pressure sensors**

The plantar pressure monitoring devices can be presented as fixed platforms or as insoles to be used directly in the footwear. Platform systems are typically constructed of several pressure sensors arranged in an array embedded in the floor or in a rigid platform. These systems can be used for static and dynamic studies, but are generally restricted to clinics and laboratories. In the case of the static tests, the patient stands still on the platform. On the other hand, for the dynamic tests, the platform is placed on the floor and the patient walks through it.

**31**

**Figure 4.**

*from [50]).*

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications*

The application of these types of measuring systems has the advantage of being easy to use, since the platforms are flat and stationary. Nevertheless, these systems also present disadvantages, since they are influential to the patient's gait, once during the examination, he/she will have to tread specific areas of the platform

Insole sensors can be incorporated into shoes, so that the measurements truly reflect the interface between the foot and the shoe. These systems, as they are flexible and portable, allow a greater accuracy of the acquired data, regarding the natural gait of the patient, and also greater variety of studies with different walking tasks, footwear, and even diverse floors/terrains [47]. However, insoles usually have a reduced number of sensors compared to platforms. The main requirements for the development of wearable/in-shoe sensors are: mobility, reduced number of cables, low power consumption, low cost, high acquisition frequency, proper sensitivity, noninvasiveness, and do not represent any danger to the user. Therefore, fiber optic sensors, due to their characteristics, have proven to be a reliable solution in this type of applications. Also, within the range of fiber optic sensors, the FBGs seem to be the best solution, since their multiplexing capability allows to have multiple sensors into a single fiber, reducing the number of cables needed in the insole. In this section, some recently developed work using optical fibers with Bragg gratings, as plantar pressure sensors in fixed platforms and in-shoe equipment, will be

The first work with FBG sensors incorporated in platforms for the measurement of plantar pressure was published in 2003, when Hao's team developed an insole shaped device with a silica optical fiber with five FBGs [48]. The insole was constituted of 10 layers of carbo-epoxy, among which the optical fiber was placed. The sensing FBG units were placed strategically at the main pressure points (heel and metatarsal areas). The device was tested in static tests to determine which areas have the greatest and lowest pressure at different user positions. The results showed

In 2014, Suresh et al*.* published a work comparing the use of FBGs and piezoelectric (PZT) sensors for gait monitoring at low and high speeds [49]. To manufacture the optical sensing platform, the FBGs were embedded between layers of a carbon composite material (CCM) in the form of an arc. After that, both types of sensors were placed on the underside of a commercial shoe (**Figure 4a**). For the dynamic test and to verify the behavior of both types of sensors, a healthy male walked on a treadmill wearing those shoes at various speeds. For the FBGs sensors, a mean pressure sensitivity of 1.3 pm/kPa was obtained. The study revealed that the FBG sensors have a better performance in the static moments and at lower speeds,

while the piezoelectric sensors had greater performance for higher speeds.

*(a) Scheme of the shoe with the attached FBG and PZT sensors (adapted from [49]); and (b) schematic representation of an arc shaped FBG pressure sensor (left) and the insole sensing scheme (right) (adapted* 

that the sensors had an average sensitivity of 5.44 pm/N.

*DOI: http://dx.doi.org/10.5772/intechopen.81136*

surface [47].

described.

### *Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications DOI: http://dx.doi.org/10.5772/intechopen.81136*

The application of these types of measuring systems has the advantage of being easy to use, since the platforms are flat and stationary. Nevertheless, these systems also present disadvantages, since they are influential to the patient's gait, once during the examination, he/she will have to tread specific areas of the platform surface [47].

Insole sensors can be incorporated into shoes, so that the measurements truly reflect the interface between the foot and the shoe. These systems, as they are flexible and portable, allow a greater accuracy of the acquired data, regarding the natural gait of the patient, and also greater variety of studies with different walking tasks, footwear, and even diverse floors/terrains [47]. However, insoles usually have a reduced number of sensors compared to platforms. The main requirements for the development of wearable/in-shoe sensors are: mobility, reduced number of cables, low power consumption, low cost, high acquisition frequency, proper sensitivity, noninvasiveness, and do not represent any danger to the user. Therefore, fiber optic sensors, due to their characteristics, have proven to be a reliable solution in this type of applications. Also, within the range of fiber optic sensors, the FBGs seem to be the best solution, since their multiplexing capability allows to have multiple sensors into a single fiber, reducing the number of cables needed in the insole. In this section, some recently developed work using optical fibers with Bragg gratings, as plantar pressure sensors in fixed platforms and in-shoe equipment, will be described.

The first work with FBG sensors incorporated in platforms for the measurement of plantar pressure was published in 2003, when Hao's team developed an insole shaped device with a silica optical fiber with five FBGs [48]. The insole was constituted of 10 layers of carbo-epoxy, among which the optical fiber was placed. The sensing FBG units were placed strategically at the main pressure points (heel and metatarsal areas). The device was tested in static tests to determine which areas have the greatest and lowest pressure at different user positions. The results showed that the sensors had an average sensitivity of 5.44 pm/N.

In 2014, Suresh et al*.* published a work comparing the use of FBGs and piezoelectric (PZT) sensors for gait monitoring at low and high speeds [49]. To manufacture the optical sensing platform, the FBGs were embedded between layers of a carbon composite material (CCM) in the form of an arc. After that, both types of sensors were placed on the underside of a commercial shoe (**Figure 4a**). For the dynamic test and to verify the behavior of both types of sensors, a healthy male walked on a treadmill wearing those shoes at various speeds. For the FBGs sensors, a mean pressure sensitivity of 1.3 pm/kPa was obtained. The study revealed that the FBG sensors have a better performance in the static moments and at lower speeds, while the piezoelectric sensors had greater performance for higher speeds.

### **Figure 4.**

*(a) Scheme of the shoe with the attached FBG and PZT sensors (adapted from [49]); and (b) schematic representation of an arc shaped FBG pressure sensor (left) and the insole sensing scheme (right) (adapted from [50]).*

*Applications of Optical Fibers for Sensing*

prevents further ulceration.

referenced as plantar pressure.

different parameters [45, 46].

**3.1 Plantar pressure sensors**

capacitive sensors, and micro-strip antennas and coils.

**3. Plantar pressure and shear analysis**

The assessment of plantar and shear pressures is of great importance for the gait health evaluation analysis, aiming to understand the effects induced in/by the body and to prevent the ulceration of the foot [40]. The pressure ulcers occur when tissue is compressed during prolonged periods of time, resulting in a wound that can infect and cause amputation, or in more severe cases, the patient's death [41]. An early identification of individuals at risk of foot ulceration (people with diabetes mellitus and peripheral neuropathy) is one of the primary means to reduce its incidence [40, 41]. Due to the poor load distribution, resulting from the reduced sensitivity of the foot, abnormally high plantar pressures occur in certain areas of the foot, and when that happens, it can lead to the growth of pressure sores in these locations [42]. The most affected areas are those with bony prominences, such as under the metatarsal bones, where the majority of plantar neuropathic ulcers occur [43]. Correct and continuous mapping of plantar pressure can prevent the occurrence of these pathologies, with the adoption of different walking habits or the use of correction equipment. On the other hand, in the case of the existence of ulcers, a redistribution of the forces imposed on the foot during walking aids healing and

The force applied to the skin surface by a supporting structure has two components: the pressure acting normal to the surface and the shear stress acting in a tangential direction. Many authors have suggested that shear stresses have a pathogenic factor in the development of plantar ulcers [40–43]. This shear stress exists if there is sliding between two surfaces (foot and shoe), and it is closely related to friction [44]. Despite the importance of shear monitoring in assessing gait patterns, only normal pressure is widely reported. The lack of a validated and commercially available shear stress sensor is one of the main reasons why shear analysis is not as

There are several solutions in the market for measuring plantar pressure, static in the form of fixed platforms, and wearable as shoes insoles. In regards of the importance of gait-related pathologies in the general population, and in the elder generation in particular, several works have been developed to improve the stateof-the-art. The literature reports the use of various technologies of plantar pressure and shear sensors, such as magneto-resistors, strain gauges, piezoelectric materials,

As an alternative to these electronic devices, optical fiber-based sensors stand out due to their small diameter (hundreds of micrometers) and robustness, biocompatibility, high precision, electromagnetic insensitivity, as well as being electrically free at the point of measurement and owning the property of being able to multiplex several sensors in the same fiber, which allows to simultaneously monitor

Following such path, research studies have been carried out with FBG-based sensors used to measure not only plantar pressure but also shear parameters.

The plantar pressure monitoring devices can be presented as fixed platforms or as insoles to be used directly in the footwear. Platform systems are typically constructed of several pressure sensors arranged in an array embedded in the floor or in a rigid platform. These systems can be used for static and dynamic studies, but are generally restricted to clinics and laboratories. In the case of the static tests, the patient stands still on the platform. On the other hand, for the dynamic tests, the platform is placed on the floor and the patient walks through it.

**30**

Other approach was made by the same team, in which similar FBG cells were incorporated in an insole structure, as can be verified in the **Figure 4b**. The device was constituted by four arc-shaped cells, strategically placed in the forefoot and heel area. In this study, the plantar pressure was analyzed in both the fixed platform and the in-shoe systems. An average pressure sensitivity of 1.2 pm/kPa was obtained [50].

In 2016, Liang et al*.* proposed a sensing system based on six FBGs inscribed into a single fiber, which was embedded in silicone rubber [51]. The data registered by the optical sensors were compared to the ones collected through an i-Step P1000 digital pressure plate with 1024 barometric sensors. For the sensors' validation, 11 participants were tested, and according to the results, the viability of the optical sensor for this kind of measurement was demonstrated. Additionally, four different foot supporting types were successfully identified.

In 2017, Domingues et al*.* reported the development of two noninvasive solutions with FBGs in silica optical fiber incorporated in cork to monitor the body center of mass displacements and vertical ground reaction forces induced in the foot plantar surface during gait [12, 32]. One of the solutions, containing five FBGs, was developed to act as a fixed platform, and the other, with six FBG sensors, to be used as an instrumented insole to be adapted in a shoe as shown in **Figure 5**. Although the insole is made of five FBGs multiplexed in the same fiber, a clear isolation of each sensing point was also demonstrated, as seen in **Figure 6a**. Upon the calibration of the sensors located at point 1 (heel area), when the increasing load is applied in that point, only the FBG 1 shows a Bragg wavelength shift, proportional to the load applied (**Figure 6b**) [12].

The obtained results demonstrated the accuracy and reliability of the proposed systems to monitor and map the vertical active forces on the foot's plantar area during gait, **Figure 7**, with a sensitivity up to 11.06 pm/N.

The top graphic representation corresponds to the values independently registered by the five FBGs along time during two gait cycles, where the sum of the forces acquired by each FBG corresponds to the typical gait pattern [12]. In more detail, in the bottom graphic representation, it is possible to see which points of the insole are more actively pressed during the stance phase of the gait cycle. The dark blue representations in the foot, corresponds to the foot area that supports a higher load in the different stages of the stance phase [12, 32].

In the same year, a polymer optical fiber (POF) sensing system based on FBGs to measure foot plantar pressure was also described [52]. The plantar pressure signals were detected by five FBGs recorded in a cyclic transparent optical polymer (CYTOP) fiber, which was embedded in a cork platform in the form of an insole to monitor plantar pressure during gait. Initially, two studies were made with the insole as a fixed platform, one in which the user walked through the sensing

**33**

tivities up to 7.8 pm/kPa.

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications*

*(a) Reflection spectra of the five FBGs multiplexed in the cork insole for three different load values; and (b)* 

*Bragg wavelength shift dependence on the load applied for FBG1 (adapted from [12]).*

structure and another where he stood in the platform just moving the body center of mass. The data obtained from this device in both tests showed good repeatability and a sensitivity twice as high as the solutions based on silica optical fiber. Additionally, a team of researchers from Shanghai presented a sensing platform based on FBGs using the fused deposition modeling (FDM) method for the construction of the structure [53]. This platform was composed of several cylindrical structures in polylactic acid (PLA) with the FBG inside them. This device was designed to be used as a fixed broad platform for plantar pressure monitoring,

*Representation of two complete gait cycles registered using a cork insole instrumented with five multiplexed* 

Finally, a noninvasive and efficient insole FBG-based architecture for monitoring plantar pressure was presented in [32]. This work stands out from the others, because the authors introduced a whole IoT solution with the insole sensors integrated with a wireless transceiver, exhibited high energy efficiency and secured data transmission, to ensure the mobility and privacy of user data. The presented data reflected the precision of the proposed system, with the sensors having sensi-

which demonstrated to have a reliable mechanical performance.

*DOI: http://dx.doi.org/10.5772/intechopen.81136*

**Figure 6.**

**Figure 7.**

*FBGs (adapted from [12, 32]).*

**Figure 5.** *Schematic representation of the cork insole FBG monitoring system (adapted from [12]).*

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications DOI: http://dx.doi.org/10.5772/intechopen.81136*

### **Figure 6.**

*Applications of Optical Fibers for Sensing*

foot supporting types were successfully identified.

proportional to the load applied (**Figure 6b**) [12].

ing gait, **Figure 7**, with a sensitivity up to 11.06 pm/N.

load in the different stages of the stance phase [12, 32].

*Schematic representation of the cork insole FBG monitoring system (adapted from [12]).*

Other approach was made by the same team, in which similar FBG cells were incorporated in an insole structure, as can be verified in the **Figure 4b**. The device was constituted by four arc-shaped cells, strategically placed in the forefoot and heel area. In this study, the plantar pressure was analyzed in both the fixed platform and the in-shoe systems. An average pressure sensitivity of 1.2 pm/kPa was obtained [50]. In 2016, Liang et al*.* proposed a sensing system based on six FBGs inscribed into a single fiber, which was embedded in silicone rubber [51]. The data registered by the optical sensors were compared to the ones collected through an i-Step P1000 digital pressure plate with 1024 barometric sensors. For the sensors' validation, 11 participants were tested, and according to the results, the viability of the optical sensor for this kind of measurement was demonstrated. Additionally, four different

In 2017, Domingues et al*.* reported the development of two noninvasive solutions with FBGs in silica optical fiber incorporated in cork to monitor the body center of mass displacements and vertical ground reaction forces induced in the foot plantar surface during gait [12, 32]. One of the solutions, containing five FBGs, was developed to act as a fixed platform, and the other, with six FBG sensors, to be used as an instrumented insole to be adapted in a shoe as shown in **Figure 5**. Although the insole is made of five FBGs multiplexed in the same fiber, a clear isolation of each sensing point was also demonstrated, as seen in **Figure 6a**. Upon the calibration of the sensors located at point 1 (heel area), when the increasing load is applied in that point, only the FBG 1 shows a Bragg wavelength shift,

The obtained results demonstrated the accuracy and reliability of the proposed systems to monitor and map the vertical active forces on the foot's plantar area dur-

The top graphic representation corresponds to the values independently registered by the five FBGs along time during two gait cycles, where the sum of the forces acquired by each FBG corresponds to the typical gait pattern [12]. In more detail, in the bottom graphic representation, it is possible to see which points of the insole are more actively pressed during the stance phase of the gait cycle. The dark blue representations in the foot, corresponds to the foot area that supports a higher

In the same year, a polymer optical fiber (POF) sensing system based on FBGs to measure foot plantar pressure was also described [52]. The plantar pressure signals were detected by five FBGs recorded in a cyclic transparent optical polymer (CYTOP) fiber, which was embedded in a cork platform in the form of an insole to monitor plantar pressure during gait. Initially, two studies were made with the insole as a fixed platform, one in which the user walked through the sensing

**32**

**Figure 5.**

*(a) Reflection spectra of the five FBGs multiplexed in the cork insole for three different load values; and (b) Bragg wavelength shift dependence on the load applied for FBG1 (adapted from [12]).*

### **Figure 7.**

*Representation of two complete gait cycles registered using a cork insole instrumented with five multiplexed FBGs (adapted from [12, 32]).*

structure and another where he stood in the platform just moving the body center of mass. The data obtained from this device in both tests showed good repeatability and a sensitivity twice as high as the solutions based on silica optical fiber. Additionally, a team of researchers from Shanghai presented a sensing platform based on FBGs using the fused deposition modeling (FDM) method for the construction of the structure [53]. This platform was composed of several cylindrical structures in polylactic acid (PLA) with the FBG inside them. This device was designed to be used as a fixed broad platform for plantar pressure monitoring, which demonstrated to have a reliable mechanical performance.

Finally, a noninvasive and efficient insole FBG-based architecture for monitoring plantar pressure was presented in [32]. This work stands out from the others, because the authors introduced a whole IoT solution with the insole sensors integrated with a wireless transceiver, exhibited high energy efficiency and secured data transmission, to ensure the mobility and privacy of user data. The presented data reflected the precision of the proposed system, with the sensors having sensitivities up to 7.8 pm/kPa.

### **3.2 Plantar pressure and shear sensors**

FBGs have also great potential for measuring shear stresses in the shoe. Although there are reports of sensors developed for shear measurement [54, 55], measuring plantar and shear pressure simultaneously is more attractive and provides more insights about the wellbeing of the foot and the overall health of the person. Due to the advantages of fiber optics, and FBGs in particular, several researchers have been working on the design of FBG-based cells able to measure these two forces simultaneously. Although the main objective is the measurement of these parameters during gait, none of the studies refers the introduction of the developed sensing cells in insoles or platforms, presenting only the cells in its isolated form.

The first work published with simultaneous shear and vertical forces sensing with FBGs goes back to the year of 2000. The team of Koulaxouzidis developed a cell, using three optical fibers with an FBG each, embedded in a block of elastic material, as schemed in **Figure 8a** [56]. The developed sensor was able to measure the vertical stress, as well as the magnitude and direction of the shear stress on its top surface. The experimental results showed a good repeatability and a resolution near to 5 kPa in the measurement of both forces. Later, in 2013, Zhang et al*.* developed an identical sensor to the previous one. In this case, two POFs with one FBG each were used, one of them was placed horizontally (hPOF, hFBG), while the other was tilted (tPOF, tFBG). Both fibers were embedded in a soft polydimethylsiloxane (PDMS) matrix, as shown in **Figure 8b** [57]. The sensor had a 27 mm length and width, and a 22 mm height. In this work, the obtained pressure sensitivity was 0.8 pm/Pa in a full range of 2.4 kPa, and the shear stress sensitivity was 1.3 pm/Pa for a full range of 0.6 kPa.

In 2015, Chethana et al*.* developed an optical sensor ground reaction force measurement platform for gait and geriatrics studies [58]. The developed system consisted of eight FBGs to measure the respective soil reaction forces on the three axes (x, y, and z). Four of the FBGs were placed at the vertices of the measuring platform, monitoring the shear motions on the x and y-axes (two for the x-axis and two for the y-axis motions detection). The remaining four FBGs were placed one on each frame supporting leg to measure the plantar pressure exerted on these zones. According to the authors, the optical fiber sensors platform for ground reaction force measurements presented a zero cross-force sensitiveness in all three loading axes [58].

In 2018, Tavares et al*.* developed a cell with the same operating principle as previously reported, but using only one silica optical fiber with two FBGs placed individually in two adjacent cavities, one made of cork and another of polylactide acid (PLA), as shown in **Figure 9** [59]. For the cells' calibration, the used method was similar to the one described in Ref. [57], and the obtained values were

### **Figure 8.**

*Schematic representation of the FBG-based sensor cell developed in (a) silica (adapted from [56]) and (b) POF (adapted from [57]) fibers.*

**35**

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications*

compared with a 3-axial electronic force sensor. The results demonstrated that the developed device is a reliable solution for simultaneous measurement of shear and vertical forces. This solution has a great advantage over previous ones, since it only requires one optical fiber, which facilitates its incorporation into insoles. Therefore, several points, along the foot plantar surface, can be measured with a single optical fiber [12, 51, 52], with the advantage of being able to simultaneously diferentiate

*Scheme of the shear and pressure sensing cell with its different components and respective dimensions (adapted* 

There are also studies using FBGs for vertical and shear forces measurements, but in which shear measurement is indirectly inferred from temperature variations. The authors argue that a rise in temperature in a certain area of the foot presupposes that there was friction between the surface of the foot and the shoe (shear force) [44, 60]. Najafi's team published a work in 2017 with the validation of a smarttextile based on fiber-optics with FBGs (SmartSox) for simultaneous measurement of temperature, pressure, and joint angles in patients with diabetic peripheral neuropathy (PND), where irregular temperature increase suggested the presence of shear forces [44]. In this study, FBG sensors were placed in socks that were successfully tested in a clinical setting by 33 individuals with PND to evaluate plantar

pressure and temperature during normal gait velocity in a clinical setting.

The knee, hip, and ankle have a key role in gait, as it allows the body locomotion with muscles' minimum energy consumption and provides stability to walk in different terrain relief. During gait, the lower limb joints act together in order to provide the smoothest locomotion for the body. In **Figure 10**, the kinematics of the lower limbs in the different phases of gait are represented, namely the stance (a)

At the beginning of the stance phase, in first double support and at the heel strike, the hip is flexed at 30°, the knee is extended and the ankle is at a neutral position. As the loading response approaches with the foot flat, the hip continues in a flexed mode as the knee starts flexing 5–10°, along with the ankle plantar flexing up to 20°, for the weight acceptance, shock absorption, and to propel the body forward. At the mid stance, the hip is extended, the knee flexed by 5–10° and the ankle is dorsi-flexed, with the purpose to move the body over the stationary foot. As the heel rises, with the ankle dorsi-flexing at 15°, the hip is extended at 15–30° and the knee is extended and then flexing. At the last point of the stance phase, in the toe off moment, the hip is flexing, the knee is also flexing at 30–40° and the ankle has a plantar flexing of 20–30°, in the preparation for the swing phase and the transfer of

At the initial swing, the hip continues flexing at 15°, the knee is flexing up to 65°, and the ankle is plantar flexed at 10° to clear the foot from the floor and advance the

*DOI: http://dx.doi.org/10.5772/intechopen.81136*

**Figure 9.**

*from [59]).*

the two diferent forces (shear and pressure).

**4. Lower limb joints monitoring**

and the swing phases (b) [14, 28].

the load to the other limb [61].

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications DOI: http://dx.doi.org/10.5772/intechopen.81136*

### **Figure 9.**

*Applications of Optical Fibers for Sensing*

for a full range of 0.6 kPa.

axes [58].

**3.2 Plantar pressure and shear sensors**

FBGs have also great potential for measuring shear stresses in the shoe. Although there are reports of sensors developed for shear measurement [54, 55], measuring plantar and shear pressure simultaneously is more attractive and provides more insights about the wellbeing of the foot and the overall health of the person. Due to the advantages of fiber optics, and FBGs in particular, several researchers have been working on the design of FBG-based cells able to measure these two forces simultaneously. Although the main objective is the measurement of these parameters during gait, none of the studies refers the introduction of the developed sensing

cells in insoles or platforms, presenting only the cells in its isolated form.

The first work published with simultaneous shear and vertical forces sensing with FBGs goes back to the year of 2000. The team of Koulaxouzidis developed a cell, using three optical fibers with an FBG each, embedded in a block of elastic material, as schemed in **Figure 8a** [56]. The developed sensor was able to measure the vertical stress, as well as the magnitude and direction of the shear stress on its top surface. The experimental results showed a good repeatability and a resolution near to 5 kPa in the measurement of both forces. Later, in 2013, Zhang et al*.* developed an identical sensor to the previous one. In this case, two POFs with one FBG each were used, one of them was placed horizontally (hPOF, hFBG), while the other was tilted (tPOF, tFBG). Both fibers were embedded in a soft polydimethylsiloxane (PDMS) matrix, as shown in **Figure 8b** [57]. The sensor had a 27 mm length and width, and a 22 mm height. In this work, the obtained pressure sensitivity was 0.8 pm/Pa in a full range of 2.4 kPa, and the shear stress sensitivity was 1.3 pm/Pa

In 2015, Chethana et al*.* developed an optical sensor ground reaction force measurement platform for gait and geriatrics studies [58]. The developed system consisted of eight FBGs to measure the respective soil reaction forces on the three axes (x, y, and z). Four of the FBGs were placed at the vertices of the measuring platform, monitoring the shear motions on the x and y-axes (two for the x-axis and two for the y-axis motions detection). The remaining four FBGs were placed one on each frame supporting leg to measure the plantar pressure exerted on these zones. According to the authors, the optical fiber sensors platform for ground reaction force measurements presented a zero cross-force sensitiveness in all three loading

In 2018, Tavares et al*.* developed a cell with the same operating principle as previously reported, but using only one silica optical fiber with two FBGs placed individually in two adjacent cavities, one made of cork and another of polylactide acid (PLA), as shown in **Figure 9** [59]. For the cells' calibration, the used method was similar to the one described in Ref. [57], and the obtained values were

*Schematic representation of the FBG-based sensor cell developed in (a) silica (adapted from [56]) and* 

**34**

**Figure 8.**

*(b) POF (adapted from [57]) fibers.*

*Scheme of the shear and pressure sensing cell with its different components and respective dimensions (adapted from [59]).*

compared with a 3-axial electronic force sensor. The results demonstrated that the developed device is a reliable solution for simultaneous measurement of shear and vertical forces. This solution has a great advantage over previous ones, since it only requires one optical fiber, which facilitates its incorporation into insoles. Therefore, several points, along the foot plantar surface, can be measured with a single optical fiber [12, 51, 52], with the advantage of being able to simultaneously diferentiate the two diferent forces (shear and pressure).

There are also studies using FBGs for vertical and shear forces measurements, but in which shear measurement is indirectly inferred from temperature variations. The authors argue that a rise in temperature in a certain area of the foot presupposes that there was friction between the surface of the foot and the shoe (shear force) [44, 60]. Najafi's team published a work in 2017 with the validation of a smarttextile based on fiber-optics with FBGs (SmartSox) for simultaneous measurement of temperature, pressure, and joint angles in patients with diabetic peripheral neuropathy (PND), where irregular temperature increase suggested the presence of shear forces [44]. In this study, FBG sensors were placed in socks that were successfully tested in a clinical setting by 33 individuals with PND to evaluate plantar pressure and temperature during normal gait velocity in a clinical setting.

### **4. Lower limb joints monitoring**

The knee, hip, and ankle have a key role in gait, as it allows the body locomotion with muscles' minimum energy consumption and provides stability to walk in different terrain relief. During gait, the lower limb joints act together in order to provide the smoothest locomotion for the body. In **Figure 10**, the kinematics of the lower limbs in the different phases of gait are represented, namely the stance (a) and the swing phases (b) [14, 28].

At the beginning of the stance phase, in first double support and at the heel strike, the hip is flexed at 30°, the knee is extended and the ankle is at a neutral position. As the loading response approaches with the foot flat, the hip continues in a flexed mode as the knee starts flexing 5–10°, along with the ankle plantar flexing up to 20°, for the weight acceptance, shock absorption, and to propel the body forward. At the mid stance, the hip is extended, the knee flexed by 5–10° and the ankle is dorsi-flexed, with the purpose to move the body over the stationary foot. As the heel rises, with the ankle dorsi-flexing at 15°, the hip is extended at 15–30° and the knee is extended and then flexing. At the last point of the stance phase, in the toe off moment, the hip is flexing, the knee is also flexing at 30–40° and the ankle has a plantar flexing of 20–30°, in the preparation for the swing phase and the transfer of the load to the other limb [61].

At the initial swing, the hip continues flexing at 15°, the knee is flexing up to 65°, and the ankle is plantar flexed at 10° to clear the foot from the floor and advance the

### **Figure 10.**

*Schematic representation of the lower limbs kinematics involved in the: (a) stance and (b) swing phases.*

limb. At the mid swing, the hip is flexed at 30°, while the knee is flexing at 25°, and the ankle is at a neutral position. At the terminal swing, the hip is flexed at 25°, the knee is extended, and the ankle is at a 0° plantar flexion, to prepare the next heel contact at the beginning of the new stance phase [61].

The use of objective techniques to evaluate the health conditions of the knee can be a powerful tool for researchers and medical staff, providing relevant information about tendon-ligament strains and vibration, pressure, angular range of movements, and even temperature [62, 63].

There are numerous conventional techniques that can be used to monitor the joint conditions, such as stereo-optic, solid state, and piezo-resistive sensing methods, which employ accelerometers, magneto-resistive sensors, flexible goniometers, electromagnetic tracking systems, among others [24, 62, 64]. However, these techniques usually require complex and expensive electronics, which are susceptible to magnetic interferences and also cannot be used in humid/wet environments. Therefore, they do not represent an ideal solution for wearable sensing configurations, where the human transpiration may influence the sensors performance. So, the increasing research in the field of optical fiber sensors has also been focusing in the introduction of FBG technology in monitoring the lower limb joints during walking. Optical fiber sensors can be easily adapted to curved surfaces and various contours of the human body, especially the knee, a joint with complex anatomy [62, 63, 65–67].

The ideal technology to monitor limb joints should be able to measure curvature, being useful not only to monitor the motion of the lower limb segments, as well

**37**

**Figure 11.**

*Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications*

as to evaluate all the corporal posture [65]. The development of a smart garment, based on FBGs and flex sensing technologies, to monitor the body posture and lower and upper limbs' movements, was reported. An FBG-based sensing belt was produced by encapsulating FBG sensors inside a synthetic silica gel, as depicted in **Figure 11**, which was afterward attached to a garment for monitoring joints and body posture. The encapsulation of the FBG was made with an applied pre-stress, so the sensor is able to monitor both extension and compression deformations. The proposed FBG belt, fixed near the limb joints, is influenced by the body posture shifts, and the consequent sensor's Bragg wavelength shift was correlated with the angles at the limb joint [65]. Although the results presented by Abro et al*.* are only related to tests made at the upper limbs, the reasonable results obtained within the tests and exercises are a good indication of its potential application for the monitor-

From the lower limb three joints (ankle, knee, and hip), the knee is one of the body joints most prone to develop osteoarthritis [68]. Therefore, the supervision and monitoring of the motion of the knee are of crucial importance in the medical

Rocha et al*.* suggest a wearable knee motion sensor, designed with a single FBG, embedded in a stretchable band of polyvinyl chloride (PVC) material and placed in the center of the knee joint, as schematized in **Figure 12a** [67]. The objective is to measure the knee movements from the straight leg to the maximum knee flexion and to obtain graphically the pattern of human gait, by monitoring flexion and extension, with the joint acting as a rotation axis, as represented in **Figure 12b**. The PVC band with the FBG was attached to an elastic ribbon (knee brace), by metallic pressure-buttons that ensure the stability of the sensing band while walking or running. In the reported work, the authors tested the proposed solution on a treadmill, under different types of run and speed, accompanied by video recorder [67]. The video was used to define the starting time of the stance and swing phases in order to correlate the data provided by the FBG sensor to the different phases of the walking

When the leg is straight, the FBG sensor is in the resting position since there is neither flexion nor extension in the optical fiber. Once the bending movement of the knee starts, during walking, it results in an extension of the optical fiber, inducing a strain in the FBG sensor, positioned at the center of the knee joint. Consequently, a positive shift of the reflected Bragg wavelength is obtained. The reverse bending movement, from the maximum knee flexion point to straight leg, leading to a relaxation of the FBG, return to its initial Bragg wavelength value [67]. By monitoring the wavelength shift during these movements, the gait pattern of the

Although the researchers Rocha et al*.* show a clear characterization of the movement of the knee joint during the gait cycle, they also point out, as a drawback, the noise induced in the signal by vibration, considering that better results are achieved at lower speed, softening the influence of the elastic factor of the knee band [67].

*Schematic representation of the FBG belt proposed by Abro et al. (adapted from [65]).*

*DOI: http://dx.doi.org/10.5772/intechopen.81136*

ing of the lower limbs motion.

routine [67, 71, 72].

patient could be characterized.

**4.1 Knee flexion-extension monitoring**

and physical rehabilitation field [37, 62, 67, 69, 70].

### *Fiber Bragg Gratings as e-Health Enablers: An Overview for Gait Analysis Applications DOI: http://dx.doi.org/10.5772/intechopen.81136*

as to evaluate all the corporal posture [65]. The development of a smart garment, based on FBGs and flex sensing technologies, to monitor the body posture and lower and upper limbs' movements, was reported. An FBG-based sensing belt was produced by encapsulating FBG sensors inside a synthetic silica gel, as depicted in **Figure 11**, which was afterward attached to a garment for monitoring joints and body posture. The encapsulation of the FBG was made with an applied pre-stress, so the sensor is able to monitor both extension and compression deformations. The proposed FBG belt, fixed near the limb joints, is influenced by the body posture shifts, and the consequent sensor's Bragg wavelength shift was correlated with the angles at the limb joint [65]. Although the results presented by Abro et al*.* are only related to tests made at the upper limbs, the reasonable results obtained within the tests and exercises are a good indication of its potential application for the monitoring of the lower limbs motion.
