This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To compare the immediate effects of walking training without or with an ankle support device (ASD) on spatiotemporal gait parameters, mobility, and satisfaction among 20 ambulatory participants with chronic stroke.
Methods
This crossover design required the participants to complete the four 30-minute walking training conditions in a randomized order: without ASD, with ankle-foot orthosis (AFO), with long ankle sling made from 3- to 4-inch elastic bandage, and with elastic ankle support equipment (EASE) developed from elastic bands with buttonholes and plastic rivets, with a 7-day washout period. Gait parameters and Timed Up and Go test (TUG) were measured before and after each training program, and satisfaction with the three ASDs was assessed upon completion.
Results
Spatiotemporal parameters (except walking cadence and symmetry) and TUG after training with a long ankle sling and EASE were significantly better than those following training without ASD and with AFO (p<0.001). Participants satisfied with both elastic ASDs in terms of dimensions, weight, safety, comfort, and effectiveness (p<0.001). The EASE was also satisfied for its ease of application and adjustment. The AFO was durable and easy to use but heavy, uncomfortable, and unsafe.
Conclusion
The elastic ASDs were designed to assist ankle movements during the stance and swing phases. Thus, they improved walking and mobility of the participants significantly greater than the training with AFO and without ASD. The findings suggest the use of a long ankle sling and EASE as an alternative ASD to promote mobility of ambulatory individuals with chronic stroke.
Adequate ankle control is essential for normal walking during both the stance and swing phases. However, sensorimotor impairments following stroke frequently distort ankle control, which affects ankle stability, balance control, walking ability, mobility, safety, and independence of the patients [1,2]. Therefore, a large proportion (up to 61%) of ambulatory individuals with stroke in a developing country are prescribed a non-hinged plastic posterior leaf spring ankle-foot orthosis (AFO) as a standard ankle support device (ASD) to assist toe clearance during the swing phase, and promote mediolateral ankle stability during the stance phase [3-5]. Previous studies have additionally reported that an AFO benefits walking ability, aerobic capacity, energy efficiency, walking speed, walking endurance, and confidence of the patients [3,6-9].
However, some ambulatory individuals with stroke discontinue using an AFO because of its weight, appearance, and pressure points due to insufficient adaptation to the foot and shoe shape causing pain and discomfort [3,10,11]. In addition, a standard AFO can restrict the ankle rocker, i.e., ankle transformation from plantarflexion to dorsiflexion, that is necessitate for body advancement at the ankle joint during the stance phase [5,12,13]. This restriction can facilitate the use of a compensatory strategy, such as anterior trunk lean, to move the body’s center of mass over the base of support during the single limb support period [14-16]. Such compensatory strategy subsequently shifts the line of gravity passing in front of the knee, leading to the passive force pushing the knee backward and the knee hyperextension, which further decreases walking efficiency of the patients [17-19]. By contrast, a hinged AFO allows the ankle rocker, but it is costly, which limits the accessibility by many patients in a developing country. The wider ankle area of a hinge mechanism also makes fitting into regular footwear more challenging, while its weight could reduce walking cadence [20,21].
Recently, elastic ASDs, namely a “long ankle sling,” was developed from a 3- to 4-inch general commercial bandage to support the ankle during the swing phase while assist the ankle rocker during the stance phase. However, a long ankle sling has limited clinical application due to its difficulty for making proper supportive force. Subsequently, the researchers have developed an alternative elastic ASD using the idea of a long ankle sling, but made from commercial elastic bands with buttonholes to allow supporting force adjustment based on individual problems easily, called “elastic ankle support equipment” (EASE). Our recent study [22] reported that wearing these elastic ASDs, both a long ankle sling and EASE, improved walking and mobility of ambulatory individuals with stroke significantly as compared to walking without ASD and walking with an AFO. This study further assessed the change of walking and mobility outcomes immediately after 30-minute training without or with ASDs among ambulatory individuals with chronic stroke. Additionally, the study compared participant satisfaction with the ASDs in this study, including a standard non-hinged AFO, a long ankle sling, and EASE. The researchers hypothesized that elastic ASDs assisted ankle movements during both the stance and swing phases. Thus, they could promote walking and mobility of the participants more effectively than walking training without ASD or with an AFO. Given that EASE is user-friendly, it promises clinical applications in clinical, community, and home-based settings.
METHODS
Participants
This crossover design study was conducted in individuals with chronic stroke who could walk independently over at least 10m with or without a walking device, i.e., functional ambulation category=3–4 [23], from several communities within a developing country (Thai Clinical Trials Registry, clinical trial registration number: TCTR20260218001). The inclusion criteria were age 40–75 years [24], had the first-stroke episode with post-stroke onset longer than 6 months [25]. The eligible participants never used any ASD with uncontrolled ankle movements due to plantarflexor spasticity with a Modified Ashworth Scale (MAS) of <2 or foot drop [22,26]. These individuals were excluded if they presented with other medical conditions that could affect the ability to participate in the study, such as having unstable medical conditions, aphasia, bilateral hemiplegia, musculoskeletal, and/or neurogenic pain with a pain scale of at least 5 out of 10 on a visual analog scale, deformity in the joints of the lower extremities, other neurological diseases, or an inability to understand and complete the study protocols. The sample size was calculated using data from 10 pilot participants for a major variable of the study, i.e., walking speed; with a confidence level set at 95% and the power of test at 90% [27], the findings indicated that the study required 17 participants. With consider a dropout rate of 15%, thus, the study needed at least 20 participants. The research protocols followed the guidelines of the Declaration of Helsinki. All participants read and signed a written informed consent document approved by the Khon Kaen University Ethics Committee for Human Research (HE671050) before taking part in the study.
Experimental procedures
Eligible individuals participated in this study five times over four weeks. On the first day, they were interviewed and assessed for their demographic and stroke characteristics. On the next day, they engaged in one of the four walking training conditions (i.e., without an ASD, with an AFO, with a long ankle sling, or with EASE, Fig. 1) in a random order using a Latin square to ensure sequencing equality with the supervision by an experienced physical therapist [28]. During the training, participants were encouraged to walk continuously at a comfortable speed in a good manner, with or without a walking device, as in their daily walking for 30 minutes (excluding rest periods). Before and after the training program, participants were assessed for the outcomes of the study without using any ASD [29]. Following a 7-day washout period [30,31], they participated in 30-minute walking training under a different condition. Details of the ASDs used in the study and the outcome measurements are as follows.
ASDs
AFO
The study applied a commercial non-hinged posterior leaf spring (i.e., the shaft covering the calf) AFO (Fig. 1B) that is commonly prescribed for individuals with stroke in general clinical settings in a developing country in a size fitting the participant’s foot [3-5,12,22].
Elastic ASDs
Elastic ASDs, including a long ankle sling and EASE (Fig. 2) [32], were developed with the aim to promote toe clearance during the swing phase while assist ankle and knee movements during the stance phase using kinematic data of gait analysis as explained in a recent study [22] (Fig. 2A). The details are explained below:
In normal walking, once the foot is placed flat on the floor, the ankle transforms from plantarflexion to dorsiflexion, known as the “ankle rocker,” to enable body advancement over the stance limb such that it resembles an inverted pendulum movement. Concurrently, the knee changes from a relatively extended position into slight flexion to optimize effective limb length for energy conservation and to act as a shock absorber during the loading response phase. Subsequently, the ankle has to change from plantarflexion to a neutral position to allow adequate toe clearance and lower limb advancement with minimizing the risk of stumble during the swing phase [15,16]. The researchers applied this information to develop elastic ASDs as follows:
(1) Long ankle sling
The long ankle sling was made using a commercial 3- to 4-inch bandage, depending on the participant’s size (Fig. 1C). The distal end was positioned at the base of the toes to maximize the lever arm length for biomechanical assistance during the swing phase (Fig. 2A, 2B). Then, the bandage was pulled up to place the proximal end at the top of the shank, just below the knee joint, to facilitate tibial advancement and slight knee flexion during the stance phase (Fig. 2B-2E) while lengthening the step length of the other limb (Fig. 1C). The two bands of the sling also allow force adjustment for proper ankle control—inversion or eversion—according to the individual’s problem (Fig. 2A, 2E).
(2) EASE
The EASE was made using four elastic bands with buttonholes and three plastic rivet buttons (Fig. 2F) to allow supporting force adjustment easily. One band with two buttons is wrapped around the base of the toes, i.e., a distal end (Fig. 2G). Another band is used as a proximal end, placed at the top of the shank, i.e., just below the knee joint, with the other two elastic bands attached to a button behind the shank (Fig. 2G, 2H). After setting a proper ankle position, each of the two bands is pulled down from the posterior aspect of the proximal end, crossing over the anterior aspect of the shank to be attached to a button on the other side of the distal end at the base of the toes (Fig. 1D, 2I, 2J). Thus, the EASE enables a proper supporting force through the increased tension and/or the number of elastic bands.
These elastic ASDs were executed by an experienced physical therapist to minimize confounding factors due to subjective judgement for individual participant factors, such as leg length, foot shape, levels of supporting forces, and a proper ankle alignment.
Outcome measurements
Before and after the training program, participants were assessed for the outcomes of the study without using any ASD [29]. Details of the tests are as follows:
Walking ability
The participants were recorded for their walking ability using a video camera-based motion capture system while they walked at their preferred and fastest speed along a 10 m walkway. The camera (GoPro Hero12 with a 120 Hz frame rate and full HD [1080p]) was mounted perpendicularly at 3.5 m from the midpoint of the walkway to capture the data of at least three stride lengths over a rhythmic phase (Fig. 3). Prior to the data recording, the system was calibrated using a known-length object. Then, two-dimensional gait analysis and manual digitization, i.e., a practical and reliable method (intraclass correlation coefficient [ICC]=0.95–0.99) for the use in general clinical and community settings, were used to analyze the spatiotemporal parameters, including the step length, stride length, cadence, walking speed, and percent step length symmetry, as follows [22,33,34]:
○ Step length (cm): the distance in horizontal pixels between the heel of one foot to the heel of the other foot (Fig. 1) and scaling with respect to the calibration object.
○ Stride length (cm): the summation of the right and left step lengths.
○ Cadence (steps/minute): the number of steps in a minute.
○ Walking speed (m/s): calculated using the formula Stridelength×Cadence120.
○ Step length symmetry (%): calculated using the formula TheshortersteplengthThelongersteplength×100.
Mobility
Participant was assessed for their mobility using the Timed Up and Go test (TUG), a reliable measure (ICC=0.99) comprising basic mobility needed in daily activities, including standing up, walking, turning around, and sitting down [34,35]. The outcomes of the test reflect daily mobility, dynamic balance ability, and fall risk [35,36]. Participants sat on a standard armchair with their back against the backrest of the chair and their arms on the armrests or a walking device. Then, they stood up from the chair, walked for 3 m, 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 according to their daily walking. The average time required over two trials was recorded [35,37,38].
Satisfaction
The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) version 2.0, a valid and reliable measure (ICC=0.75–0.90), was used to assess user satisfaction [38]. Participants answered the eight items of the device domain but not the four items of service domain, with each item rated on a 5-point ordinal scale from 1 (not satisfied at all) to 5 (very satisfied) [5,22,39,40].
Walking and mobility outcomes were measured before and after each training condition, while the QUEST was assessed after completing all training conditions by a highly reliable rater (ICC=0.96–0.98). Participants wore a lightweight safety belt around their waists, with a physical therapist walking alongside them to ensure their safety. They could rest as needed or until their vital signs returned to baseline values.
Statistical analysis
The Shapiro–Wilk test indicated that the data were normally distributed. Descriptive statistics were applied to explain the participants’ demographics and stroke characteristics, and the findings of the study. The repeated-measures ANOVA were used to compare the findings among the four conditions. Then the post-hoc (Bonferroni) test was utilized to analyze all pairwise comparisons. The level of statistical significance was set at p<0.05.
RESULTS
Twenty ambulatory participants with stroke, with a mean age of approximately 55 years and normal body mass index, completed the study. The majority were male (60.0%), walked without a walking device (80.0%), and had right hemiplegia (70.0%) from ischemic stroke (65.0%), with a mean post-stroke duration of approximately 15 months. All participants had impaired sensorimotor functions with mild spasticity of the plantarflexor muscles (MAS=1.2, Table 1).
Walking and mobility data
The pre-test data of all outcome measures showed no significant differences among the four conditions (p=0.10–0.51), suggesting that the 7-day washout period was sufficient to minimize potential carryover effects. Thus, the study reported the data of all participants for every variable. For walking ability, the results demonstrated similar trends when assessed at either preferred or fastest speeds. After 30-minute training, participants improved most variables, especially after training with elastic ASDs (p<0.001), except percent step length symmetry and walking cadence (p>0.05, Fig. 4). The step length of both the affected and non-affected sides, stride length, walking speed, and TUG data after walking training with the long ankle sling or EASE were also significantly better than those after the training with no ASD or the AFO (p<0.01). However, percent step length symmetry and walking cadence showed no significant differences among the conditions (p>0.05, Fig. 4).
User satisfaction
The QUEST 2.0 data indicated that the participants were mostly satisfied with the dimensions, weight, safety, comfort, and effectiveness of the long ankle sling and EASE (p<0.001, Table 2). The AFO received the highest scores for durability and ease of use but the lowest scores for weight, comfort, and safety/security. Some participants reported unsafe and pain in certain areas of the foot while walking with the AFO. In contrast, the long ankle sling received the lowest satisfaction regarding the ease of adjustment and application, while EASE scored lowest for the durability (p<0.01, Table 2).
DISCUSSION
This randomized crossover study investigated the therapeutic effects of walking training with the three ASDs, namely an AFO, a long ankle sling, and EASE, compared to walking without an ASD on the spatiotemporal gait parameters and TUG data among 20 ambulatory participants with stroke. Without carryover effects after 7-day intervals, the significant improvements observed after the 30-minute walking training with the long ankle sling and EASE suggest an immediate clinical benefit of the elastic ASDs used in the study.
The significant improvement in walking and TUG outcomes after 30-minute walking training in all conditions supported the clinical benefit of task-specific walking training among ambulatory individuals with chronic stroke (p<0.05, Fig. 4) [37]. However, the significant differences among the conditions after the training suggest the contribution of ASD used in the study. All three ASDs are designed to support the foot in a neutral position during the swing phase, thereby promoting toe clearance and extending the step length of the affected side [17,21,22]. However, an AFO is rather heavy, i.e., received the lowest satisfaction scores on its weight (Table 2), that interferes the ability to lengthen a step length of the affected foot, particularly among individuals with motor weakness who had never previously used it (as were the participants in this study). The findings are coherent with existing data that reported the effects of AFO’s weight distorting gait performance of the patients [3-5,40,41]. Therefore, the increased step length of the affected side after training with the long ankle sling and EASE was significantly greater than that after training without ASD and with AFO (p<0.001, Fig. 4).
The significant improvement in the step length of the non-affected side, and time to complete the TUG after training using elastic ASDs may suggest the additional benefit of their assisting force during the stance phase (Fig. 2A). Once the affected foot was placed flat on the floor, the elastic pulling force from the proximal end at the top of the tibia aided tibial advancement that promoted slight knee flexion and ankle rocker during the stance phase. This assisting force may also shift the body’s center of mass and the line of gravity passing over a small base of support during the single limb support period on the affected side. Such force may promote body stability while movements and lengthened the step length of the non-affected foot, especially when most participants in this study (80.0%, Table 1) walked without a walking device. As a result, the improvement in the TUG and step length of the non-affected side following training with elastic ASDs was significantly greater than that following the training without ASD and with AFO (p<0.001, Fig. 4). The increment of the step length of both the affected and non-affected sides after training with the long ankle sling or EASE was also accompanied by significantly better improvement in the stride length and walking speed (p<0.001, Fig. 4) [15,16].
In contrast, using a non-hinged AFO imposed a force resisting ankle transformation limiting tibial advancement at the ankle joint and bodyweight shifting anteriorly over the base of support [5,12,13]. The rigid nature and weight of the AFO also increase physical demand in lifting the foot from the floor and moving the lower limb forward, affecting the step lengths of the affected and non-affected sides, as well as walking cadences of the participants. The rigid plastic AFO also limited ankle movements, affecting mobility and balance ability, as reflected by the TUG outcomes (Fig. 4). This assumption was associated with previous studies that reported the resistive force of AFO against ankle dorsiflexion, which reduced the step length of the non-affected side and interfered with the balance ability of individuals with stroke [7-9,22]. Some participants also reported the decreased safety and security, along with increased pain in areas of the affected foot. These findings align with previous research that indicated adverse effects related to AFO use, including skin irritation and rashes at contact points [3,5].
The non-significant differences in walking cadence and step length symmetry across the walking training conditions may reflect participant characteristics and the effects of the ASDs in this study. Participants with poor ankle control and mild plantarflexor spasticity (MAS=1.2, Table 1) could have had limited push-off ability during the late stance period [12]. Thus, the hip flexors play a crucial role in initiating the swing phase and promoting walking cadence [41], while the ASDs were primarily designed to promote ankle, not hip, control. Consequently, the walking cadences of the participants showed no significant differences across the conditions when assessed at a preferred speed (p>0.05). However, when assessed at the fastest and safe speed, the elastic pulling force from the distal end might facilitate the toe clearance and the ability to move forward. Thus, participants demonstrated significant improvement in walking cadence after training using the long ankle sling and EASE (p<0.05, Fig. 4). Moreover, the non-significant differences in percent step length symmetry, when assessed at either preferred or fastest walking speed, may reflect the similar change in the step lengths of both affected and non-affected sides following all training conditions. Nonetheless, the weight and rigid manner of the AFO may distort movements of the participants. Therefore, they showed the significantly greater asymmetrical step length after 30-minute walking training with an AFO (p<0.05, Fig. 4).
The present findings suggest immediate training effects of elastic ASDs, particular the EASE with the cost of less than US$1, on walking and mobility of ambulatory individuals with chronic stroke that can be applied in various clinical and home-based settings. However, the study contains some limitations. Participants were those who could walk independently with or without a walking device and had never used any ASD to minimize confounding factors due to external assistance from a physical therapist and prior experience of using an ASD. Most participants also had mild spasticity and walked without a walking device. Additionally, various types of AFOs with different degrees of ankle dorsiflexion allowance are available, while this study used a plastic non-hinged AFO as it is a standard prescription in general clinical settings of a developing country [3,5,12,22]. Therefore, the findings cannot be generalized to all ambulatory individuals with stroke or assumed to demonstrate the superior effects of elastic ASDs over other types of AFOs. The training effects were measured immediately after each training session; thus, they cannot indicate learning effects, i.e., motor adaptation, occurred in the participants. Furthermore, the findings were discussed according to the direction of assisting forces without clear kinematic data. Therefore, further randomized controlled trials involving individuals with stroke who have various levels of walking impairment with data confirmation from standard measures, such as the Fugl-Meyer Assessment of Motor Recovery, along with data comparisons with other types of AFOs, and assessments for kinematic data as well as during a retention period, are needed to support the clinical contribution of elastic ASDs to the walking and mobility of ambulatory individuals with stroke.
In conclusion, The present findings support the use of the long ankle sling and EASE as alternative, effective, and inexpensive ASDs. The EASE is user-friendly design to allow supportive force adjustment easily by modifying the number of elastic bands and tension applied, with a cost of less than US$1. Thus, it can be used to promote walking and mobility of ambulatory stroke patients in various clinical and community settings, especially among those with limited 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 Fundamental Fund (FF), Khon Kaen University, for the fiscal year 2027 from National Science, Research and Innovation Fund (NSRF), Thailand.
AUTHOR CONTRIBUTION
Conceptualization: Chanata T, Amatachaya S, Nithiatthawanon T, Wannapakhe J, Chanwised W, Wiyanad A, Thaweewanakij T, Namwong W. Methodology: Chanata T, Amatachaya S, Chanwised W, Wiyanad A, Thaweewanakij T, Namwong W. Data curation: Chanata T, Nithiatthawanon T, Namwong W. Formal analysis: Chanata T, Amatachaya S, Wiyanad A, Thaweewanakij T. Funding acquisition: Amatachaya S. Project administration: Amatachaya S. Resources: Amatachaya S, Chanwised W. Supervision: Amatachaya S, Wannapakhe J. Software: Nithiatthawanon T. Investigation: Wannapakhe J. Writing – original draft: Chanata T, Wiyanad A. Writing – review & editing: Amatachaya S, Nithiatthawanon T, Wannapakhe J, Chanwised W, Thaweewanakij T, Namwong W. Approval of final manuscript: all authors.
Fig. 1.
Walking training 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.
Fig. 2.
Elastic ankle support devices in the study. (A) Concepts for the development of elastic ankle support devices in the study. (B-E) The method of making a long ankle sling. (F-J) Equipment and method of making elastic ankle support equipment. Modified from Amatachaya S. [Walking training in patients with stroke]; 2025. p. 367-70. Thai [32] with original copyright holder's permission.
Fig. 3.
Setting for spatiotemporal data recording.
Fig. 4.
The spatiotemporal and Timed Up and Go data of the participants before and after training in all four training conditions, including with no ankle support device (no ASD), with ankle foot orthosis (AFO), with long ankle sling (LAS), and with elastic ankle support equipment (EASE). *p<0.05, **p<0.01, and ***p<0.001.
Table 1.
Demographic and stroke characteristics of the participants
Characteristic
Value (n=20)
Age (yr)
54.7±14.1
Body mass index (kg/m2)
22.8±2.5
Post-stroke duration (mo)
14.9±8.8
Fugl-Meyer Assessment, sensory section
Upper extremity (total 12 scores)
9.4±4.1
Lower extremity (total 12 scores)
8.6±4.6
Motricity Index
Upper extremity (total 99 scores)
53.8±27.5
Lower extremity (total 99 scores)
52.5±23.8
Sex, female
8 (40.0)
Hemiplegic side: right
14 (70.0)
Modified Ashworth Scale of plantarflexor muscle
1.2±0.8
Types of stroke
Ischemic
13 (65.0)
Hemorrhagic
7 (35.0)
Walking device use: tripod cane
4 (20.0)
Values are presented as mean±standard deviation or number (%).
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
LAS
EASE
1. The dimensions (size, height, length, and width) of your assistive device?
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.
QUEST, Quebec User Evaluation of Satisfaction with Assistive Technology; AFO, ankle-foot orthosis; LAS, long ankle sling; EASE, elastic ankle support equipment.
Significant difference at
*p<0.05 and
**p<0.001.
Superscripts infer the group with statistically significant differences from the indicated group, whereby
a)AFO,
b)LAS, and
c)EASE.
REFERENCES
1. Algurén B, Lundgren-Nilsson A, Sunnerhagen KS. Functioning of stroke survivors--a validation of the ICF core set for stroke in Sweden. Disabil Rehabil 2010;32:551-9.
3. Dajpratham P, Pongakkasira C, Terachinda P, Phutthakumnerd W, Sirirak P. Patient compliance and factors related to usage of plastic ankle-foot orthoses by chronic stroke patients. ASEAN J Rehabil Med 2021;32:29-33.
4. Poolpipat P, Suksathien R. The use of plastic ankle-foot orthosis prescribed for patients with foot drop: the application and related factors. ASEAN J Rehabil Med 2023;33:81-6.
5. 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.
7. de Wit DC, Buurke JH, Nijlant JM, Ijzerman MJ, Hermens HJ. The effect of an ankle-foot orthosis on walking ability in chronic stroke patients: a randomized controlled trial. Clin Rehabil 2004;18:550-7.
8. Doğan A, Mengüllüoğlu M, Özgirgin N. Evaluation of the effect of ankle-foot orthosis use on balance and mobility in hemiparetic stroke patients. Disabil Rehabil 2011;33:1433-9.
9. Hyun CW, Kim BR, Han EY, Kim SM. Use of an ankle-foot orthosis improves aerobic capacity in subacute hemiparetic stroke patients. PM R 2015;7:264-9.
10. van der Wilk D, Hijmans JM, Postema K, Verkerke GJ. A user-centered qualitative study on experiences with ankle-foot orthoses and suggestions for improved design. Prosthet Orthot Int 2018;42:121-8.
11. Nakipoğlu Yüzer GF, Koyuncu E, Çam P, Özgirgin N. The regularity of orthosis use and the reasons for disuse in stroke patients. Int J Rehabil Res 2018;41:270-5.
12. 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.
13. Carse B, Bowers R, Meadows BC, Rowe P. The immediate effects of fitting and tuning solid ankle-foot orthoses in early stroke rehabilitation. Prosthet Orthot Int 2015;39:454-62.
14. Fatone S, Gard SA, Malas BS. Effect of ankle-foot orthosis alignment and foot-plate length on the gait of adults with poststroke hemiplegia. Arch Phys Med Rehabil 2009;90:810-8.
17. Johnston TE, Keller S, Denzer-Weiler C, Brown L. A clinical practice guideline for the use of ankle-foot orthoses and functional electrical stimulation post-stroke. J Neurol Phys Ther 2021;45:112-96.
18. de Sèze MP, Bonhomme C, Daviet JC, Burguete E, Machat H, Rousseaux M, et al. Effect of early compensation of distal motor deficiency by the Chignon ankle-foot orthosis on gait in hemiplegic patients: a randomized pilot study. Clin Rehabil 2011;25:989-98.
19. Gatti MA, Freixes O, Fernández SA, Rivas ME, Crespo M, Waldman SV, et al. Effects of ankle foot orthosis in stiff knee gait in adults with hemiplegia. J Biomech 2012;45:2658-61.
20. Radtka SA, Skinner SR, Johanson ME. A comparison of gait with solid and hinged ankle-foot orthoses in children with spastic diplegic cerebral palsy. Gait Posture 2005;21:303-10.
22. Chanata T, Namwong W, Thaweewanakij T, Wiyanad A, Amatachaya P, Amatachaya S. Elastic ankle support devices effectively promoted walking ability and mobility of ambulatory individuals with stroke. Ann Rehabil Med 2025;49:426-36.
23. Lee JM, Kim EJ, An SH. Responsiveness and change in functional mobility measures according to ankle plantar flexor spasticity severity in subacute stroke. Physiother Res Int 2026;31:e70245.
25. 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.
26. Yamamoto S, Motojima N, Kobayashi Y, Osada Y, Tanaka S, Daryabor A. Ankle-foot orthosis with an oil damper versus nonarticulated ankle-foot orthosis in the gait of patients with subacute stroke: a randomized controlled trial. J Neuroeng Rehabil 2022;19:50.
28. 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.
29. Sánchez Silverio V, Abuín Porras V, Rodríguez Costa I, Cleland JA, Villafañe JH. Effects of action observation training on the walking ability of patients post stroke: a systematic review. Disabil Rehabil 2022;44:7339-48.
30. Karakkattil PS, Trudelle-Jackson E, Medley A, Swank C. Effects of two different types of ankle-foot orthoses on gait outcomes in patients with subacute stroke: a randomized crossover trial. Clin Rehabil 2020;34:1094-102.
32. Amatachaya S. [Walking training in patients with stroke]. In: Amatachaya S, editor. [Physical therapy on mobility and walking of patients with stroke]. Chulabook center; 2025. p. 367-70. Thai.
33. 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 AHS 2024;36:21-30.
36. 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.
37. 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.
38. Thaweewannakij T, Wilaichit S, Chuchot R, Yuenyong Y, Saengsuwan J, Siritaratiwat W, et al. Reference values of physical performance in Thai elderly people who are functioning well and dwelling in the community. Phys Ther 2013;93:1312-20.
39. 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.
40. 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.
41. Jiroumaru T, Hyodo Y, Wachi M, Oka Y, Fujikawa T. Correction: hip flexor muscle activation across gait phases in healthy young adults: effects of step length and cadence adjustments at a constant walking speed. Cureus 2025;17:c373.
Immediate Effects of Walking Training With Elastic Ankle Support Devices on Walking and Mobility of Ambulatory Individuals With Stroke
Fig. 1. Walking training 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.
Fig. 2. Elastic ankle support devices in the study. (A) Concepts for the development of elastic ankle support devices in the study. (B-E) The method of making a long ankle sling. (F-J) Equipment and method of making elastic ankle support equipment. Modified from Amatachaya S. [Walking training in patients with stroke]; 2025. p. 367-70. Thai [32] with original copyright holder's permission.
Fig. 3. Setting for spatiotemporal data recording.
Fig. 4. The spatiotemporal and Timed Up and Go data of the participants before and after training in all four training conditions, including with no ankle support device (no ASD), with ankle foot orthosis (AFO), with long ankle sling (LAS), and with elastic ankle support equipment (EASE). *p<0.05, **p<0.01, and ***p<0.001.
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Fig. 4.
Graphical abstract
Immediate Effects of Walking Training With Elastic Ankle Support Devices on Walking and Mobility of Ambulatory Individuals With Stroke
Characteristic
Value (n=20)
Age (yr)
54.7±14.1
Body mass index (kg/m2)
22.8±2.5
Post-stroke duration (mo)
14.9±8.8
Fugl-Meyer Assessment, sensory section
Upper extremity (total 12 scores)
9.4±4.1
Lower extremity (total 12 scores)
8.6±4.6
Motricity Index
Upper extremity (total 99 scores)
53.8±27.5
Lower extremity (total 99 scores)
52.5±23.8
Sex, female
8 (40.0)
Hemiplegic side: right
14 (70.0)
Modified Ashworth Scale of plantarflexor muscle
1.2±0.8
Types of stroke
Ischemic
13 (65.0)
Hemorrhagic
7 (35.0)
Walking device use: tripod cane
4 (20.0)
Items of the QUEST (version 2.0)
Types of ankle support device
p-value
AFO
LAS
EASE
1. The dimensions (size, height, length, and width) of your assistive device?
3.05±0.94
4.10±0.78a)
4.30 ±0.65a)
<0.001**
2. The weight of your assistive device?
2.65±0.67
4.05 ±0.68a)
4.35± 0.67a)
<0.001**
3. The ease in adjusting (fixing and fastening) the parts of your assistive device?
4.70±0.47b)
1.40±0.75
3.80±0.76b)
<0.001**
4. How safe and secure your assistive device is?
3.15±0.81
4.25±0.71a)
4.35±0.58a)
<0.001**
5. The durability (endurance and resistance to wear) of your assistive device?
4.75±0.44b),c)
3.20±0.61
2.40± 0.82
<0.001**
6. How easy it is to use your assistive device?
3.90±0.20b)
3.05±1.14
3.85±0.48b)
0.008*
7. How comfortable your assistive device is?
2.80±0.69
3.95±0.60a)
4.15±0.67a)
<0.001**
8. How effective your assistive device is (the degree to which your device meets your needs)?
2.65±0.67
3.90± 0.44a)
4.20±0.52a)
<0.001**
Table 1. Demographic and stroke characteristics of the participants
Values are presented as mean±standard deviation or number (%).
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.
QUEST, Quebec User Evaluation of Satisfaction with Assistive Technology; AFO, ankle-foot orthosis; LAS, long ankle sling; EASE, elastic ankle support equipment.
Significant difference at
p<0.05 and
p<0.001.
Superscripts infer the group with statistically significant differences from the indicated group, whereby
, Sugalya Amatachaya, PT, PhD1,2
