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To compare the walking ability, mobility, and satisfaction among 24 ambulatory participants with stroke while walking under four conditions: without an ankle support device (ASD), with a plastic ankle-foot orthosis (AFO), and with two types of elastic ASDs—namely, a long ankle sling made from a 3- to 4-inch bandage, and elastic ankle support equipment (EASE) made from elastic bands with buttonholes and rivet buttons.
Methods
This crossover design study assessed spatiotemporal gait variables and mobility using the Timed Up and Go test (TUG) while participants walked under the four conditions in random order. They then completed a self-report questionnaire regarding satisfaction with the three ASDs. The findings were compared using the Friedman and Wilcoxon signed rank test.
Results
The participants’ spatiotemporal and TUG data improved significantly when walking with a long ankle sling and EASE compared to the other two conditions (p<0.05). Participants satisfied with the dimensions, weight, safety, security, and effectiveness of the long ankle sling and EASE (p<0.001). The EASE was also comfortable and easy to adjust, whereas the AFO was noted for its durability (p<0.01).
Conclusion
With the design to promote mobility during both the swing and stance phases, the present findings support the clinical benefits of elastic ASDs, specifically a long ankle sling and EASE. The EASE is also user-friendly; thus, it can be applied in various clinical and community settings, particularly in those with limited budget.
A lack of ankle control can significantly impact foot clearance during the swing phase, subsequently affecting the safety, walking, and mobility of individuals with stroke [1]. Consequently, a posterior leaf spring ankle-foot orthosis (AFO) is a standard ankle support device (ASD) commonly prescribed in clinical settings to promote toe clearance and forward movement of the hemiplegic lower limb during the swing phase [2-4]. Previous studies have reported clinical benefits of the AFO, including improved ankle control, postural stability, walking speed, walking symmetry, and walking efficiency [5-8].
Nonetheless, a rigid nature of a plastic AFO could restrict the tibial advancement or ankle rocker (i.e., the ability of body advancement at the ankle joint, and thus the ankle has to change from plantarflexion to dorsiflexion) during the stance phase [9,10]. As a result, the individuals may develop compensatory strategies, such as anterior trunk lean and knee hyperextension, to enable forward shifting of the body center of mass over the base of support during the single limb support period [11,12].
Consequently, the researchers developed a method of bandage-assisted walking, referred to as a “long ankle sling,” to support the ankle during the swing phase while still allowing for body advancement at the ankle and promoting slight knee flexion during the stance phase [13,14]. However, the long ankle sling requires skillful application to provide appropriate supporting force, making it challenging to implement in routine clinical practice. To address this issue, the researchers further developed an alternative ASD using elastic bands with buttonholes, named “elastic ankle support equipment (EASE),” to facilitate easy force adjustments based on individual needs.
However, there is no clear evidence supporting the effectiveness of these elastic ASDs compared to walking without an ASD and with a standard AFO. Thus, this study compared walking ability and mobility of ambulatory individuals with stroke in four conditions: walking without an ASD, with an AFO, with a long ankle sling, and with EASE. Moreover, participants’ satisfaction with the three types of ASDs was compared. The researchers hypothesized that the elastic force from a long ankle sling and the EASE enabled movements during both the stance and swing phases, thereby potentially improving participants’ walking and mobility more effectively than walking with an AFO and without any ASD. As the EASE is user-friendly, it facilitates clinical application. The present findings may offer an alternative ASDs to promote walking ability and mobility of ambulatory individuals with stroke in general clinical settings.
METHODS
Participants
This crossover design study was conducted in hospitals and various communities within a developing country. Eligible participants included individuals who experienced their first stroke episode and had never used any ASDs. The inclusion criteria were: age between 40 and 75 years [15,16], post-stroke onset of ≥3 months [17], independent walking over at least 10 m with or without a walking device, and uncontrolled ankle movements (plantarflexor spasticity with a modified Ashworth Scale score of ≤2 or foot drop) [9,10]. Individuals were excluded if they had conditions affecting their participation in the study, such as unstable medical conditions, bilateral hemiplegia, musculoskeletal pain with a visual analog scale score for pain of at least 5 out of 10, deformities of the lower extremity joints, plantarflexor shortening or contracture, other neurological diseases, or an inability to understand and complete the study protocols.
The sample size was calculated using walking speed data, a primary outcome of the study, of 10 pilot participants, with the mean difference of 0.08 m/s, standard deviation of 0.05 m/s, confidence level set at 95% (significance level=0.05; Zα⁄2=1.96) and the power of test set at 90% (zβ=1.28) [18]. The findings indicated that the study required at least 24 participants. All participants read and signed a written informed consent form approved by the Khon Kaen University Ethics Committee for Human Research (HE671050) before participation in the study.
Research protocols
The participants involved in the study for 2 days. On the first day, they were interviewed and assessed for their demographics and stroke characteristics. On the second day, they were assessed for the outcomes of the study in four conditions; walking without an ASD, with an AFO, with a long ankle sling, and with the EASE (Fig. 1), in a random order using the Latin square to ensure sequencing equality when the order of conditions might interfere with the outcomes [19]. Details of the ASDs and outcomes are as follows:
ASDs used in the study
(1) AFO: This study used a commercial, non-articulated, or posterior leaf spring AFO (Fig. 1B), which is commonly prescribed for a patient with walking deficits in general clinical settings of a developing country, in a size fitting with the participant’s foot [9,10,20].
(2) Long ankle sling: It was done using a 3- to 4-inch bandage to promote normal gait kinematics both the stance and swing phases. Normally, body advancement occurs at the ankle joint of the stance limb after the foot placing flat on the floor, as the so-called ankle rocker, whereby the ankle has to change from plantarflexion to dorsiflexion to enable an invert pendulum movement of the body. During this period, the knee also has to change from full extension to slight flexion to lower the upward trajectory of the body center of mass for effective leg length and energy optimization, and for being shock absorber during a stance phase. During a swing phase, the lower extremity must be lifted up from the floor by changing from extension to flexion to minimize the risks of stumbling and falling [12,21]. Consequently, a long ankle sling was made with its distal end placed at the base of the toes and its proximal end at the top of the shank, at the level below the knee joint, to maximize the length of the lever arms for biomechanical assistance during the stance phase (proximal end) and the swing phase (distal end) (Fig. 1C, 2A, 2B). In addition, the two bands of the long sling enable force adjustment for proper ankle control (inversion or eversion) according to the patient’s problems [13,14].
(3) EASE: The EASE was developed based on a concept similar to that of a long ankle sling, utilizing commercial elastic bands with buttonholes for easy force adjustments (Fig. 1D, 2A, 2C, 2D). The method requires four elastic bands, each 30 cm in length and 2 cm in width, along with three plastic rivet buttons (Fig. 2D). One band, equipped with two buttons, is formed into a circle to fit the participant’s foot width securely and is placed around the forefoot at the base of the toes. Another band is wrapped around the upper end of the shank, just below the knee joint, using a button located behind the shank, with the other two elastic bands attached to this button. After establishing the proper ankle position, each of the two bands is drawn from the posterior aspect of the proximal end, crossing over the anterior aspect of the shank to attach to a button on the opposite side of the distal end. The tension was adjusted as the participants walked comfortably, while successfully supported the ankle at the proper angle [13,14].
Outcome measures
The walking and mobility outcomes of the four conditions were assessed by an excellent reliability examiner (intraclass correlation coefficient [ICC]=0.96–0.98), in a random order. Participants wore appropriately sized sandal sports shoes (Fig. 1), which were provided by the researchers, with a practice session to familiarize themselves with the ASDs and the shoes. An examiner walked alongside the participant without interruption to ensure their safety and the accuracy of the outcomes. The participants could rest between the trials and the tests as needed. Thereafter, participants completed a self-report questionnaire regarding their satisfaction with the three ASDs used in the study. Details of the outcomes are as follows:
(1) Walking ability: A video camera-based motion capture system was used to analyze walking ability during self-selected, and fast and safe speeds along a 10 m walkway. The camera (GoPro Hero12 with a 120-Hz frame rate and full HD [1080p]) was mounted perpendicularly 3.5 m from the walkway to capture the data of the three stride lengths in the middle of the walkway (rhythmic phase). Prior to the data recording, the system was calibrated using a known-length object. The spatiotemporal data were then analyzed using a two-dimensional gait analysis and manual digitization, a practical and excellent reliability method (ICC=0.95–0.99) for using in clinical and community settings as follows [22-24]:
∘ Step length (cm): the distance of the horizontal pixels between the heel of one foot and the heel of the other foot, and scaling with respect to the calibration object.
∘ Stride length (cm): the average summation of the right and left step lengths.
∘ Cadence (steps/minute): the number of steps taken in 1 minute.
∘ Walking speed (m/s): calculated using the formula Stride length × Cadence120
∘ Step length symmetry (%): calculated using the formula Average data of the shorter step lengthAverage data of the longer step length×100
(2) Mobility: Participants were assessed for their mobility using the Timed Up and Go test (TUG), a reliable measure (ICC=0.99) comprising basic mobility needed for daily living, including sitting-to-standing, walking, and turning around [25,26]. Thus, the outcomes reflect basic daily mobility, dynamic balance control, and fall risk [25,27]. The participants stood up from a standard armchair, walked for 3m, turned around a traffic cone, walked back, and sat down on the chair at a fast and safe speed with or without a walking device [15,25,27].
(3) Satisfaction: The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST, version 2.0), a standard valid and reliable (ICC=0.75–0.90) instrument, was used to identify user satisfaction [28]. The tool consists of 8 items in the device domain, and 4 items in the service domain, with each item rated on a 5-point ordinal scale ranging from 1 (not satisfied at all) to 5 (very satisfied) [28,29]. In this study, the participants answered only the 8 items in the device domain of the instrument [9].
Statistical analysis
Descriptive statistics were applied to explain the participants’ demographics, stroke characteristics, and the findings of the study. With the non-normal distribution, the Friedman test was used to analyze the differences among the four conditions. Then the Wilcoxon signed rank test was used to analyze all pairwise comparisons. The statistical significance level was set at p<0.05.
RESULTS
Demographics
Twenty-four ambulatory participants with stroke (67% male, with approximately equal numbers of those with right and left hemiplegia) completed the study. Their mean age was 52 years, with normal body mass index, and the post-stroke duration longer than one year (Table 1). Third-quarters (75%) of the participants had ischemic stroke, and a quarter of them walked with a tripod cane. All participants had sensorimotor impairments with mild spasticity (mean modified Ashworth Scale score, 1.07±0.7; Table 1). Their average preferred walking speed was 0.53 m/s.
Walking ability
The participants’ spatiotemporal variables improved significantly when they walked with a long ankle sling and the EASE as compared with when they walked without an ASD and with an AFO (p<0.05; Fig. 3). The participants’ median walking speed when walking with a long ankle sling and the EASE was significantly faster than that when walking without an ASD (median preferred speed [Q1:Q3]=0.52 [0.33:0.70], 0.56 [0.39:0.78], and 0.67 [0.33:0.80]; and median fastest speed [Q1:Q3]=0.70 [0.39:0.86], 0.73 [0.47:0.96], and 0.77 [0.43:1.02] for walking without an ASD, with a long ankle sling, and with the EASE, respectively; Fig. 3A). By contrast, the participants tended to walk slower when they used an AFO (median preferred speed [Q1:Q3]=0.48 [0.34:0.73] and median fastest speed [Q1:Q3]=0.56 [0.39:0.89]) when compared with that of walking without an ASD (Fig. 3A).
Furthermore, while walking with a long ankle sling and the EASE, participants increased their step lengths, particularly on the non-affected side (Fig. 3C), which consequently led to an increase in their stride lengths compared to data from walking without an ASD and with an AFO (p<0.05; Fig. 3B-D). These changes were accompanied by the greater step length symmetry, particularly when compared to the condition with an AFO (Fig. 3E). Moreover, the participants’ cadence when walking with a long ankle sling and the EASE was significantly higher than that when walking without an ASD and with an AFO (p<0.05; Fig. 3F). However, the step length of the affected side showed no significant difference among the condition with ASDs, i.e., with an AFO, long ankle sling, and EASE (p>0.05; Fig. 3B).
Mobility
When using a long ankle sling and the EASE, the participants’ time to complete the TUG significantly decreased compared to the conditions without an ASD and with an AFO (p<0.001; Fig. 3G).
User satisfaction
The long ankle sling and EASE received significantly higher satisfaction scores than the AFO for the dimensions, weight, safety and security, and effectiveness (p<0.001; Table 2). The EASE was significantly better comfort than the other ASDs. In contrast, the AFO had the highest scores for the ease of fixing and fastening, as well as durability (p≤0.01; Table 2). Nonetheless, some participants with intact sensation reported pain in their malleolus and heel areas while walking with an AFO.
DISCUSSION
Improvement in walking and mobility is a key rehabilitation goal for ambulatory individuals with stroke. This study compared walking and mobility of ambulatory participants with stroke while walking under four conditions, including with walking without an ASD, with a standard AFO, with a long ankle sling, and with the EASE. In addition, the study assessed the participants’ satisfaction with the use of three ASDs. The findings support the clinical benefits of elastic ASDs, i.e., a long ankle sling and the EASE, on spatiotemporal gait variables and mobility of the participants with non-functional walking, i.e., walking speed slower than 0.6 m/s [30].
Elastic ASDs in this study, a long ankle sling and EASE, were designed not only to support the foot during the swing phase, but also to promote ankle rocker during the stance phase [13,14]. During a swing phase, elastic pulling force from the distal end of these ASDs assisted toe clearance and forward movement of the hemiplegic limb, similar to that observed when walking with the AFO (Fig. 1C, 1D, 2A-C). Therefore, the step length of the affected side showed no significant differences among the three conditions with ASDs (p>0.05; Fig. 3B). Nevertheless, the elastic pulling force of the long ankle sling and EASE also facilitated upward movements of the limb during the swing phase. As a result, the participants’ walking cadence while walking with elastic ASDs was significantly higher than that when walking without an ASD and with the AFO (Fig. 3F).
During the stance phase, the elastic pulling force from the proximal end at the top of the tibia promoted slight knee flexion, and tibial advancement at the ankle joint that facilitated the invert pendulum movement of the body [11-14]. Consequently, the body’s center of mass and the line of gravity can be positioned over a small base of support during the single limb support period on the hemiplegic limb. These effects could increase the step length of the non-affected side compared to walking without an ASD or with an AFO (Fig. 3C). These increments were accompanied by significant improvements in the participants’ stride length, walking speed, as well as mobility and dynamic balance ability, as assessed using the TUG, when they walked with the long ankle sling and EASE (Fig. 3A, D, G).
In contrast, a plastic AFO imposed a resisting force for ankle transformation that limited tibial advancement at the ankle joint and bodyweight shifting anteriorly over the base of support [9,11,12,31,32]. Consequently, the participants had a significantly shorter step length on the non-affected side when walking with the AFO compared to when walking with a long ankle sling and EASE (Fig. 3C). In addition, the rigid nature and weight of the AFO increased burden for the ability to lift the foot from the floor, adversely affecting the participants’ walking cadence (Fig. 3F) [9,33]. Thus, walking speeds and mobility of the participants decreased when using an AFO (Fig. 3A, G). A solid nature of the AFO additionally resulted in some participants experiencing pain in their foot areas. Previous studies have reported adverse events related to AFO use, including interference with gait performance and balance ability in stroke survivors, along with increased skin irritation and rashes in the contact areas [9,33,34].
Data from the QUEST 2.0 questionnaire further support the clinical application of the EASE in terms of dimensions, weight, ease of adjustment, safety and security, effectiveness, and comfort. The participants expressed similar satisfaction levels between the long ankle sling and the EASE, except for ease of adjustment. Conversely, they reported satisfaction with the AFO regarding ease in clinical application and durability (Table 2).
The present findings support the use of elastic ASDs, including a long ankle sling and EASE, as alternative, effective, and inexpensive ASDs to promote walking and mobility among ambulatory individuals with stroke who walked non-functionally. Given its user-friendly design and the ability to easily adjust supportive force by modifying the number of elastic bands and tension, with a cost of less than US$1, the EASE can be used to promote walking and mobility of ambulatory stroke patients in various clinical and community settings, especially in those with limited budget. However, this study has some limitations. As the first study reported clinical benefit of the elastic ASDs, the study assessed the outcomes while participant walked with and without an ASD in a single trial. Such data cannot clearly indicate the durability of the elastic used for the ASDs. In addition, the study did not assess stroke severity of the participants but reported their walking ability as compared to the standard criterion (<0.6 m/s indicated the ability of non-functional walking) [30]. Moreover, this study used a plastic solid AFO as a standard ASD because it is commonly prescribed for individuals with walking deficits in general clinical settings of the country [9,10,18,28]. In fact, various types of AFOs are available, both long and short AFO with various degrees of dorsiflexion allowance, which could benefit tibial advancement during the stance phase. Thus, the present findings cannot fully support the clinical advantages of the elastic ASDs over other types of AFOs. Furthermore, most participants in this study had mild spasticity and walked without a walking device. None exhibited plantarflexor shortening or contracture, a common problem found in stroke survivors. Moreover, the outcomes were assessed using time-based and field tests to enable data collection in various clinical and community settings. Therefore, further randomized controlled trials with the assessment for stroke severity are needed to confirm the effects of walking training using elastic ASDs compared to other articulated AFOs among stroke survivors with pronounced spasticity and plantarflexor shortening, utilizing kinetic and kinematic data assessments to support their clinical usefulness and durability.
Conclusion
This study highlighted the clinical benefit of elastic ASDs that facilitated the necessary movements during both the stance and swing phases. Given the ease of adjustment and application, the EASE may be effectively used to promote walking and mobility in ambulatory individuals with stroke who walk non-functionally across various clinical and community settings, especially those with restrict budget.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
This research has received funding supported by the Scholarship under Research Assistant Program from Khon Kaen University (RA2566-M205), the Fundamental Fund (FF), Khon Kaen University, for the fiscal year 2026 from National Science, Research and Innovation Fund (NSRF), Thailand.
AUTHOR CONTRIBUTION
Conceptualization: Amatachaya S, Chanata T, Namwong W, Wiyanad A, Thaweewanakij T, Amatachaya P. Data curation: Chanata T, Amatachaya S, Namwong W, Wiyanad A, Amatachaya P. Investigation: Amatachaya S, Namwong W, Wiyanad A, Thaweewanakij T, Amatachaya P. Methodology: Chanata T, Amatachaya S, Wiyanad A, Thaweewanakij T, Amatachaya S. Formal analysis: Chanata T. Funding acquisition: Amatachaya S, Thaweewanakij T. Project administration: Amatachaya S. Visualization: Amatachaya S, Chanata T. Resources: Amatachaya S, Thaweewanakij T, Amatachaya P. Supervision: Amatachaya S, Namwong W, Wiyanad A, Thaweewanakij T. Validation: Amatachaya S. Writing – original draft: Chanata T, Amatachaya S. Writing – review and editing: Amatachaya S, Namwong W, Thaweewanakij T, Wiyanad A, Amatachaya P. Approval of final manuscript: all authors.
Fig. 1.
Testing conditions in the study. (A) Without ankle support device. (B) With an ankle-foot orthosis. (C) With a long ankle sling. (D) With elastic ankle support equipment. Figures illustrate font view, initial stance, late stance, and swing phases, respectively.
Fig. 2.
A long ankle sling and elastic ankle support equipment (EASE). (A) Biomechanical assistance for the development of long ankle sling and EASE. (B) Assisting force of a long ankle sling during the stance (the upper arrows) and swing (the lower arrows) phases. (C) Assisting force of the EASE during the stance (the upper arrows) and swing (the lower arrows) phases. (D) Equipment used for the EASE.
Fig. 3.
Spatiotemporal and mobility outcomes of the participants. (A) Walking speed. (B) Step length of the affected side. (C) Step length of the non-affected side. (D) Stride length. (E) Step length symmetry. (F) Cadence. (G) Timed Up and Go test. The data of each box are presented for the condition without ankle support device (black), with ankle-foot orthosis (grey), with a long ankle sling (yellow), and with the elastic ankle support equipment (orange), respectively. *p<0.05, **p<0.01, and ***p<0.001.
Table 1.
Demographics and stroke characteristics of the participants (n=24)
Variable
Value
95% CI
Age (yr)
52.1 (12.6)
46.8–57.4
Body mass index (kg/m2)
23.8 (3.1)
22.5–25.1
Post-stroke duration (mo)
16.2 (11.6)
11.3–21.1
Fugl-Meyer Assessment, sensory section
Upper extremity (total 12 scores)
9.4 (4.4)
7.5–10.8
Lower extremity (total 12 scores)
8.7 (4.8)
6.6–10.7
Motricity Index
Upper extremity (total 99 scores)
54.3 (28.7)
42.4–66.1
Lower extremity (total 99 scores)
50.8 (26.7)
39.6–62.1
Modified Ashworth Scale of plantarflexor muscles
1.07 (0.7)
0.7–1.5
Sex, male
16 (67)
Type of stroke
Ischemic
18 (75)
Hemorrhagic
6 (25)
Hemiplegic side: right
14 (58)
Walking device use: tripod cane
6 (25)
Values are presented as mean (standard deviation) or number (%).
CI, confidence interval.
Table 2.
The QUEST (version 2.0) of the participants
Items of the QUEST (version 2.0)
Types of ankle support device
p-value
AFO
Long ankle sling
EASE
1. The dimensions (size, height, length, and width) of your assistive device?
2.81 (0.22)
4.24 (0.18)A
4.38 (0.16)A
<0.001
2. The weight of your assistive device?
2.43 (0.20)
4.24 (0.13)A
4.43 (0.14)A
<0.001
3. The ease in adjusting (fixing and fastening) the parts of your assistive device?
4.52 (0.21)L
1.67 (0.99)
3.48 (0.19)L
<0.001
4. How safe and secure your assistive device is?
2.86 (0.24)
4.52 (0.13)A
4.48 (0.13)A
<0.001
5. The durability (endurance and resistance to wear) of your assistive device?
4.81 (0.11)L,E
3.43 (0.17)
3.14 (0.18)
<0.001
6. How easy it is to use your assistive device?
4.10 (0.20)L,E
3.00 (0.29)
3.81 (0.13)
0.01
7. How comfortable your assistive device is?
3.00 (0.29)
3.81 (0.13)
4.10 (0.20) A
0.01
8. How effective your assistive device is (the degree to which your device meets your needs)?
2.67 (0.21)
4.00 (0.13)A
4.38(0.14)A
<0.001
Each item has a score ranging from 1 (not satisfied at all) to 5 (very satisfied).
Values are presented as mean (standard deviation).
p-value from the ANOVA with repeated measures. Superscripts infer to the group with statistically significant differences from the indicated group, whereby A=AFO, L=long ankle sling, E=EASE.
QUEST, Quebec User Evaluation of Satisfaction with Assistive Technology; AFO, ankle-foot orthosis; EASE, elastic ankle support equipment.
REFERENCES
1. Eng JJ, Tang PF. Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence. Expert Rev Neurother 2007;7:1417-36.
3. Tsuchiyama K, Mukaino M, Ohtsuka K, Matsuda F, Tanikawa H, Yamada J, et al. Effects of ankle-foot orthoses on the stability of post-stroke hemiparetic gait. Eur J Phys Rehabil Med 2022;58:352-62.
4. Chen CPC, Suputtitada A, Chatkungwanson W, Seehaboot K. Anterior or posterior ankle foot orthoses for ankle spasticity: which one is better? Brain Sci 2022;12:454.
5. Esquenazi A, Ofluoglu D, Hirai B, Kim S. The effect of an ankle-foot orthosis on temporal spatial parameters and asymmetry of gait in hemiparetic patients. PM R 2009;1:1014-8.
6. Leung J, Moseley A. Impact of ankle-foot orthoses on gait and leg muscle activity in adults with hemiplegia: systematic literature review. Physiotherapy 2003;89:39-55.
7. Franceschini M, Massucci M, Ferrari L, Agosti M, Paroli C. Effects of an ankle-foot orthosis on spatiotemporal parameters and energy cost of hemiparetic gait. Clin Rehabil 2003;17:368-72.
9. Thitithunwarat N, Krityakiarana W, Kheowsri S, Jongkamonwiwat N, Richards J. The effect of a modified elastic band orthosis on gait and balance in stroke survivors. Prosthet Orthot Int 2023;47:466-72.
10. Yamamoto S, Fuchi M, Yasui T. Change of rocker function in the gait of stroke patients using an ankle foot orthosis with an oil damper: immediate changes and the short-term effects. Prosthet Orthot Int 2011;35:350-9.
15. Thaweewannakij T, Suwannarat P, Mato L, Amatachaya S. Functional ability and health status of community-dwelling late age elderly people with and without a history of falls. Hong Kong Physiother J 2015;34:1-9.
17. Huitema RB, Hof AL, Mulder T, Brouwer WH, Dekker R, Postema K. Functional recovery of gait and joint kinematics after right hemispheric stroke. Arch Phys Med Rehabil 2004;85:1982-8.
19. Steen IN, Campbell MK, Eccles MP, Grimshaw JM, Ramsay CR, Russell IT. The use of Latin squares and related block designs in implementation research. J Clin Epidemiol 2014;67:1299-301.
20. Abe H, Michimata A, Sugawara K, Sugaya N, Izumi S. Improving gait stability in stroke hemiplegic patients with a plastic ankle-foot orthosis. Tohoku J Exp Med 2009;218:193-9.
21. Webster JB, Darter BJ. Principles of normal and pathologic gait. In: Webster JB, Murphy DP, editors. Atlas of orthoses and assistive devices. 5th ed. Elsevier; 2019. p. 49-62.e1.
24. Nithiatthawanon T, Teesintanakorn A, Sanjai C, Hengchanoknun K, Saikaew N, Simarattanamongkhon S, et al. Concurrent validity of two-dimensional motion analysis using Kinovea for measuring spatiotemporal gait parameters in healthy individuals. Arch Allied Health Sci 2024;36:21-30.
26. Lyders Johansen K, Derby Stistrup R, Skibdal Schjøtt C, Madsen J, Vinther A. Absolute and relative reliability of the Timed 'Up & Go' test and '30second Chair-Stand' test in hospitalised patients with stroke. PLoS One 2016;11:e0165663.
27. Phonthee S, Amatachaya P, Sooknuan T, Amatachaya S. Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial. Eur J Phys Rehabil Med 2020;56:14-23.
28. Aledda S, Galeoto G, Fabbrini G, Lucibello L, Tofani M, Conte A, et al. A systematic review of the psychometric properties of Quebec user evaluation of satisfaction with assistive technology (QUEST). Disabil Rehabil Assist Technol 2024;19:1228-35.
29. Demers L, Weiss-Lambrou R, Ska B. Development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Assist Technol 1996;8:3-13.
30. Lord SE, McPherson K, McNaughton HK, Rochester L, Weatherall M. Community ambulation after stroke: how important and obtainable is it and what measures appear predictive? Arch Phys Med Rehabil 2004;85:234-9.
31. Sankaranarayan H, Gupta A, Khanna M, Taly AB, Thennarasu K. Role of ankle foot orthosis in improving locomotion and functional recovery in patients with stroke: a prospective rehabilitation study. J Neurosci Rural Pract 2016;7:544-9.
32. Daryabor A, Arazpour M, Aminian G. Effect of different designs of ankle-foot orthoses on gait in patients with stroke: a systematic review. Gait Posture 2018;62:268-79.
33. Totah D, Menon M, Jones-Hershinow C, Barton K, Gates DH. The impact of ankle-foot orthosis stiffness on gait: a systematic literature review. Gait Posture 2019;69:101-11.
34. Geboers JF, Drost MR, Spaans F, Kuipers H, Seelen HA. Immediate and long-term effects of ankle-foot orthosis on muscle activity during walking: a randomized study of patients with unilateral foot drop. Arch Phys Med Rehabil 2002;83:240-5.
Elastic Ankle Support Devices Effectively Promoted Walking Ability and Mobility of Ambulatory Individuals With Stroke
Fig. 1. Testing conditions in the study. (A) Without ankle support device. (B) With an ankle-foot orthosis. (C) With a long ankle sling. (D) With elastic ankle support equipment. Figures illustrate font view, initial stance, late stance, and swing phases, respectively.
Fig. 2. A long ankle sling and elastic ankle support equipment (EASE). (A) Biomechanical assistance for the development of long ankle sling and EASE. (B) Assisting force of a long ankle sling during the stance (the upper arrows) and swing (the lower arrows) phases. (C) Assisting force of the EASE during the stance (the upper arrows) and swing (the lower arrows) phases. (D) Equipment used for the EASE.
Fig. 3. Spatiotemporal and mobility outcomes of the participants. (A) Walking speed. (B) Step length of the affected side. (C) Step length of the non-affected side. (D) Stride length. (E) Step length symmetry. (F) Cadence. (G) Timed Up and Go test. The data of each box are presented for the condition without ankle support device (black), with ankle-foot orthosis (grey), with a long ankle sling (yellow), and with the elastic ankle support equipment (orange), respectively. *p<0.05, **p<0.01, and ***p<0.001.
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Graphical abstract
Elastic Ankle Support Devices Effectively Promoted Walking Ability and Mobility of Ambulatory Individuals With Stroke
Variable
Value
95% CI
Age (yr)
52.1 (12.6)
46.8–57.4
Body mass index (kg/m2)
23.8 (3.1)
22.5–25.1
Post-stroke duration (mo)
16.2 (11.6)
11.3–21.1
Fugl-Meyer Assessment, sensory section
Upper extremity (total 12 scores)
9.4 (4.4)
7.5–10.8
Lower extremity (total 12 scores)
8.7 (4.8)
6.6–10.7
Motricity Index
Upper extremity (total 99 scores)
54.3 (28.7)
42.4–66.1
Lower extremity (total 99 scores)
50.8 (26.7)
39.6–62.1
Modified Ashworth Scale of plantarflexor muscles
1.07 (0.7)
0.7–1.5
Sex, male
16 (67)
Type of stroke
Ischemic
18 (75)
Hemorrhagic
6 (25)
Hemiplegic side: right
14 (58)
Walking device use: tripod cane
6 (25)
Items of the QUEST (version 2.0)
Types of ankle support device
p-value
AFO
Long ankle sling
EASE
1. The dimensions (size, height, length, and width) of your assistive device?
2.81 (0.22)
4.24 (0.18)A
4.38 (0.16)A
<0.001
2. The weight of your assistive device?
2.43 (0.20)
4.24 (0.13)A
4.43 (0.14)A
<0.001
3. The ease in adjusting (fixing and fastening) the parts of your assistive device?
4.52 (0.21)L
1.67 (0.99)
3.48 (0.19)L
<0.001
4. How safe and secure your assistive device is?
2.86 (0.24)
4.52 (0.13)A
4.48 (0.13)A
<0.001
5. The durability (endurance and resistance to wear) of your assistive device?
4.81 (0.11)L,E
3.43 (0.17)
3.14 (0.18)
<0.001
6. How easy it is to use your assistive device?
4.10 (0.20)L,E
3.00 (0.29)
3.81 (0.13)
0.01
7. How comfortable your assistive device is?
3.00 (0.29)
3.81 (0.13)
4.10 (0.20) A
0.01
8. How effective your assistive device is (the degree to which your device meets your needs)?
2.67 (0.21)
4.00 (0.13)A
4.38(0.14)A
<0.001
Table 1. Demographics and stroke characteristics of the participants (n=24)
Values are presented as mean (standard deviation) or number (%).
CI, confidence interval.
Table 2. The QUEST (version 2.0) of the participants
Each item has a score ranging from 1 (not satisfied at all) to 5 (very satisfied).
Values are presented as mean (standard deviation).
p-value from the ANOVA with repeated measures. Superscripts infer to the group with statistically significant differences from the indicated group, whereby A=AFO, L=long ankle sling, E=EASE.
QUEST, Quebec User Evaluation of Satisfaction with Assistive Technology; AFO, ankle-foot orthosis; EASE, elastic ankle support equipment.
, Wilairat Namwong, PT, PhD1,2
