Effect of ankle-foot orthosis on paretic gastrocnemius and tibialis anterior muscles contraction of stroke survivors during walking: a pilot study

Effect of ankle-foot orthosis on paretic gastrocnemius and tibialis anterior muscles contraction of stroke survivors during walking: a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effect of ankle-foot orthosis on paretic gastrocnemius and tibialis anterior muscles contraction of stroke survivors during walking: a pilot study Wei Liu, Hui-Dong Wu, Yu-Ying Li, Ringo Tang-Long Zhu, Yu-Yan Luo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4217969/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Ankle-foot orthosis (AFO) is commonly prescribed for stroke survivors with foot drop to aid in foot clearance while walking and reduce fall risk. However, its impact on the contraction patterns of paretic ankle muscles remains inconclusive. This pilot study investigated the contraction of paretic tibialis anterior (TA) and medial gastrocnemius (MG) muscles in twenty sub-acute stroke patients wearing AFO during walking using a wearable dynamic ultrasound imaging and motion sensors. Results showed an increase in TA muscle thickness throughout a gait cycle ( p > 0.05) and a significant increase in TA muscle surface mechanomyography (sMMG) signal during pre- and initial swing phases ( p 0.05), aligning more closely with healthy adults' trends throughout a gait cycle. MG sEMG signal significantly decreased during the initial and mid-swing phases when wearing AFO ( p < 0.05). The TA-MG co-contraction index notably decreased during initial and mid-swing phases with AFO ( p < 0.05). These findings suggest that AFO can promptly influence the contraction patterns of paretic ankle muscles during walking in stroke patients, but further research is needed to understand its long-term effects. Health sciences/Diseases/Cardiovascular diseases/Vascular diseases/Cerebrovascular disorders/Stroke Health sciences/Anatomy/Musculoskeletal system Health sciences/Health care/Medical imaging/Ultrasonography Stroke ankle-foot orthosis gastrocnemius muscle tibialis anterior muscle contraction walking Figures Figure 1 Figure 2 Figure 3 Introduction Foot drop is a prevalent and debilitating condition that often appears following a stroke. It is characterized by weakened or absent voluntary ankle dorsiflexion and a dragging or slapping gait pattern. This issue can result in diminished balance and mobility [ 1 ], as well as an elevated risk of falls [ 2 ]. As a result, individuals who have had a stroke may experience restrictions in their daily activities [ 3 ] and a lower quality of life [ 4 ]. The primary cause of foot drop after a stroke is typically associated with muscle weakness or paralysis in the ankle dorsiflexors, often accompanied by high muscle tone and possible contracture in ankle plantar flexors [ 5 ]. There are various treatment options available to manage foot drop and improve functional outcomes following a stroke. Physical therapy plays a crucial role in rehabilitation, focusing on strengthening the affected/paretic muscles, improving balance and coordination, and retraining the affected muscles to regain control and function [ 6 , 7 ]. Besides physical therapies, certain assistive devices such as an ankle-foot orthosis (AFO) can provide stability and prevent foot drop by maintaining the foot in a neutral or slightly dorsiflexed position [ 8 ]. This helps to enhance foot clearance while walking and reduces the risk of falls in stroke patients [ 8 ]. Understanding more on the changes in paretic ankle muscle activity while wearing AFOs could offer more evidence for future clinical practice. Previous research has demonstrated that AFOs can promptly enhance an individual's walking speed, balance, energy expenditure, and overall gait biomechanics [ 9 , 10 ]. However, their effect on the muscle activity of dorsiflexors and plantar flexors of the paretic side in post-stroke patients has remained inconsistent and unconcluded. Murayama and Yamamoto have utilized surface electromyography (sEMG) to monitor tibialis anterior (TA) and soleus (SOL) muscles’ activity during walking and discovered that the plantarflexion movement reduced by AFO can augment the activity of TA muscle during the loading response phase and the activity of the SOL muscle during the stance phase, resulting in improved stability and propulsion [ 11 ]. Meanwhile, traditional treatment approaches may sometimes avoid the use of AFO due to concerns about possible disuse atrophy of the TA muscle [ 12 , 13 ], as immobilization by AFO could inhibit the eccentric contraction of the TA muscle during walking. Some previous studies have indicated that individuals using AFO exhibited reduced sEMG activity of the TA muscle from the swing to the loading response phase, compared to those walking without AFO [ 12 , 13 ]. This implies the risk of TA muscle disuse atrophy with prolonged AFO use. In contrast, Nikamp et al. have noted that although a more pronounced decrease in sEMG activity of the TA muscle was observed in individuals with AFO compared to those without AFO in the early stages of treatment, this difference disappeared after 26 weeks [ 14 ]. Therefore, it is essential to further explore the impact of using AFO on the paretic ankle dorsiflexors and plantar flexors in stroke survivors, particularly with the potential application of more advanced technologies. A variety of sensors and tools have been employed to study and assess muscle activity in different conditions. Among them, sEMG can detect the electrical signals of a muscle, while surface mechanomyography (sMMG) sensors can measure the mechanical activities of a muscle, both from the skin surface in stroke survivors [ 14 – 17 ]. This enhances our understanding of muscle performance and the underlying mechanisms of muscle adaptations during various treatments or interventions. Concurrently, imaging techniques have been used to visualize the internal structure and morphology of muscles, aiding in the assessment of muscle atrophy post-stroke. Magnetic resonance imaging (MRI) can quantify parameters related to skeletal muscle quantity, such as muscle volume and cross-sectional area [ 18 ]. However, its clinical application for post-stroke muscle assessment is relatively limited due to high costs, time consumption, and labor intensity [ 19 ], as well as challenges in dynamic settings. Ultrasound imaging has gained attention for its ability to non-invasively and affordably assess muscles' internal morphology without ionizing radiation [ 20 ]. Monjo et al. [ 21 ] and Gonzalez-Buonomo et al. [ 22 ] have utilized ultrasound imaging and observed reduced muscle thickness in the paretic lower extremity of post-stroke individuals. Nevertheless, previous technical constraints restricted these technologies to evaluating muscle contraction patterns and internal morphological changes only in static conditions (i.e., recumbent [ 21 , 22 ] or sitting [ 21 ] position) among participants. To understand the lower-extremity muscles' activity and internal morphology during dynamic or walking conditions, a wearable ultrasound imaging and sensing system has been developed in our previous work. This system consisted of a wearable ultrasound probe and multiple motion sensors to simultaneously measure the muscle's ultrasound image, muscle sEMG and sMMG activity, and the plantar force during walking [ 23 ]. It has been applied in healthy young adults and post-stroke individuals to capture their ankle muscle activity during natural walking without any interventions [ 17 , 23 ]. However, the changes in ankle muscle activity in post-stroke individuals while walking with AFO have remained unclear and merits further study. To address the research gaps mentioned earlier, this study utilized the innovative wearable ultrasound imaging and sensing system to comprehensively examine the impact of wearing a solid AFO on the internal contraction patterns and morphological variations of stroke survivors' TA and medial gastrocnemius (MG) muscles during walking. It was hypothesized that the use of AFO would positively influence the contraction patterns of the TA and MG muscles among post-stroke participants. The findings could provide valuable insights for the orthotic management of foot drop in stroke survivors and enhance the evidence-based practice in the future. Methods Participants Participants should meet the following inclusion criteria: (1) first stroke episode within 6 months; (2) hemiparesis due to unilateral ischemic or hemorrhagic stroke; (3) ability to walk at least eight meters without assistance; (4) passive ankle dorsiflexion range of motion of at least 0° (i.e., the neutral position). Patients were excluded if they had (1) cognitive impairment, (2) uncontrolled cardiovascular or respiratory disorders, or (3) fracture or muscle disorders affecting mobility. Informed consent forms were signed once the eligible patients agreed to participate in this study. This study was approved by Chinese Clinical Trial Registry (Ref: ChiCTR2300074539). Ethical approval was granted by Kunming Medical University Medical Ethics Committee (Ref: KMMU2023MEC149) and all procedures were conducted in accordance with the Helsinki Declaration of 1975. Wearable ultrasound imaging and sensing system As detailed previously [ 23 ], the wearable system included a wearable ultrasound probe (band width: 7.5 MHz ± 35%, frame rate: 10 Hz), two sets of sEMG electrodes (272-Bx, Noraxon USA Inc, Scottsdale, AZ, USA), an sMMG sensor (N1000060, VTI Technologies Oy, Vantaa, Finland), and three thin-film force sensors (A301, Tekscan Co., Ltd., South Boston, MA, USA). These components were utilized to capture the muscle's real-time B-mode ultrasound image, electrical activity, mechanical activity, and the plantar force for identifying gait cycles [ 23 ], respectively. Experimental procedure Subjective assessments were firstly conducted for each participant. A comprehensive description of the experimental procedures was given. The participant’s stage of stroke recovery was assessed using the Brunnstrom Approach [ 24 ], muscle tone of plantar flexors at the paretic side was assessed using the Modified Ashworth Scale [ 25 ], and balance performance was assessed using the Berg Balance Scale [ 26 ] in accordance with the established protocols [ 27 ]. Then each participant accomplished the instrumented walking trials with the wearable ultrasound imaging and sensing system placed on the paretic side. Before the walking trials, ultrasound images of the paretic MG and TA muscles were captured separately for each participant in a comfortable standing position. These images served as the baseline thickness measurements for the study. The participant was then equipped with a prefabricated solid posterior leaf-spring AFO (272-Bx, Noraxon USA Inc, Scottsdale, AZ, USA), following the manufacturer’s instructions. The participant was directed to walk approximately twenty meters to acclimate to the AFO, during which he/she was instructed to activate the paretic TA and MG muscles while walking with the AFO. Subsequently, the participant was fitted with the wearable ultrasound imaging and sensing system. The ultrasound probe was positioned longitudinally on the paretic MG muscle belly, with one set of sEMG electrodes and the sMMG sensor placed parallel to the ultrasound probe on the paretic MG muscle belly. Another set of sEMG electrodes was positioned on the paretic TA muscle. Additionally, three thin-film force sensors were placed underneath the first and fifth metatarsal heads (1st and 5th MTH) and the heel of the paretic foot. Once properly set up, the participant was instructed to walk three consecutive trials on flat ground at a comfortable speed, with each trial covering approximately eight meters. The same procedures were repeated to evaluate the paretic MG muscle activity while walking without an AFO, and the paretic TA muscle activity while walking with and without an AFO [ 28 ]. The sequence for capturing the TA and MG muscles activity with and without wearing the AFO was randomized for each participant. Data processing and analysis For each walking condition, three complete gait cycles were extracted from the middle portion of each of the three walking trials for further processing using MATLAB (Version 2016b, The MathWorks Inc, Natick, MA, USA). To ensure consistency, all data were resampled to represent the 0-100% gait cycle with a 5% interval [ 23 ]. Each gait cycle was divided into seven phases: loading response (LR, 0–10%), mid-stance (MSt, 10%-30%), terminal stance (TSt, 30%-50%), pre-swing (PSw, 50%-60%), initial swing (ISw, 60%-70%), mid-swing (MSw, 70%-85%), and terminal swing (TSw, 85%-100%) phases [ 29 ]. sMMG and sEMG signal processing and analysis The sMMG and sEMG data were filtered using a fourth-order Butterworth band-pass filter (5–50 Hz for MMG and 30–500 Hz for EMG), followed by rectification and additional filtering with a moving-average filter using a temporal window of 0.101 seconds. The data were then normalized to the peak values that observed within the three extracted gait cycles [ 23 ]. The mean amplitude value of the processed signal within each 5% interval of a gait cycle was used for further analysis. Besides, concerning the sEMG data, the co-contraction index (CI) was examined to measure the co-contraction pattern of TA and MG muscles in various gait phases while walking. In the LR, ISw, MSw, and TSw phases, the TA muscle functioned as the agonist muscle, whereas the MG muscle functioned as the antagonist muscle [ 15 ]. Thus, the CI was determined as [ 15 ]: \(\text{C}\text{I}=\frac{2{\text{I}}_{\text{M}\text{G}}}{{\text{I}}_{\text{M}\text{G}}+{\text{I}}_{\text{T}\text{A}}}\) *100(1) In the MSt and TSt phases, the MG muscle was anticipated to be the agonist muscle, while the TA muscle was expected to be the antagonist muscle [ 15 ]. Hence, the CI was computed as follows [ 15 ]: \(\text{C}\text{I}=\frac{2{\text{I}}_{\text{T}\text{A}}}{{\text{I}}_{\text{M}\text{G}}+{\text{I}}_{\text{T}\text{A}}}\) *100(2) In Equations (1) and (2), I MG was calculated as the integral area under the curve that created by the normalized sEMG signal of the MG muscle, while I TA was calculated as the integral area under the curve that created by the normalized sEMG signal of the TA muscle, during the corresponding phases. The CI was calculated for each gait phase, except for the PSw phase, as the roles of TA and MG muscles as agonist and antagonist were reversed during this phase [ 15 ]. Ultrasound image processing and analyses A skilled practitioner manually annotated all the muscle ultrasound imaging data by marking the upper and lower muscle boundaries on each extracted ultrasound imaging frame post-experiment. A custom MATLAB algorithm was utilized to determine the muscle area by measuring the area between the marked upper and lower muscle boundaries on each ultrasound imaging frame. The muscle area was then divided by the width of the ultrasound image (30 mm) to calculate the average muscle thickness for each ultrasound image. The average muscle thickness values from three consecutive baseline ultrasound images, captured while the participant's ankle joint was in a comfortable standing position, were averaged to establish the baseline muscle thickness. This baseline thickness was considered as the reference value and set as "100%" during the normalization process. To normalize the ultrasound imaging data, the average muscle thickness of each ultrasound imaging frame was divided by the baseline muscle thickness first and then multiplied by 100%, resulting in the normalized average muscle thickness in percentage. The mean of such normalized thickness values within each 5% interval of a gait cycle was utilized for further statistical analyses [ 28 ]. Statistical analyses Statistical analyses were conducted using SPSS 25.0 software, with a significance level set at 0.05. The test-retest reliability of the collected data across three repetitive gait cycles for each walking condition was assessed using the intraclass correlation coefficient (ICC). The paired t-test was used to compare the differences in normalized muscle thickness, sEMG, sMMG, and plantar force of the paretic side among participants with and without the use of AFO during walking. Results Demographics and subjective assessment results As shown in Table 1 , a total of 20 sub-acute stroke survivors (13 males and 7 females) were recruited from three hospitals in Yunnan province, China. The average age of the participants was 53.0 ± 13.3 years (mean ± standard deviation), and their average body mass index (BMI) was 24.5 ± 2.7. All participants were within 1 to 6 months post-stroke, with Brunnstrom Scale ranging from III to VI. The muscle tone of the plantar flexors, assessed by the Modified Ashworth Scale, was 1.6 ± 1.3; and the Berg Balance Scale Score was 35.6 ± 8.8. Table 1 Characteristics of stroke participants (n = 20) Gender (M/F) Cause of stroke (hemorrhagic/ Ischemic) Age (years) BMI Brannstrom Scale (III/IV/V/VI) Months since stroke Paretic leg (L/R) Modified Ashworth Scale BBS 13/7 8/12 53.0 ± 13.3 (range: 39.0–68.0) 24.5 ± 2.7 (range: 18.7–29.3) 9/8/2/1 2.9 ± 2.0 (range: 1.0–6.0) 9/11 1.6 ± 1.3 (range: 0–4) 35.6 ± 8.8 (range: 29.0–53.0) (Note: M/F: male/female; BMI: body mass index; L/R: left/right; Modified Ashworth Scale: the tone of gastrocnemius muscle on the paretic side; BBS: Berg Balance Scale; data are presented as mean ± standard deviation and range.) Test–retest reliability Table 2 displays the ICC values for various parameters, including muscle thickness, sEMG signal, sMMG signal, and plantar force within each 5% interval of a gait cycle for different walking conditions. The test-retest reliability of the wearable system for measuring TA and MG muscle thickness remained consistent among participants, regardless of AFO usage, with ICC values ranging from 0.880 to 0.991 (TA) and 0.876 to 0.994 (MG), respectively ( p < 0.05). For the sEMG signals of the MG and TA muscles, most ICC values exceeded 0.70, with a small portion ranging from 0.46 to 0.70 ( p < 0.05). The ICC values for the sMMG signals of the TA and MG muscles were relatively lower and more variable, with most values falling between 0.61 and 0.88, and a few between 0.39 and 0.59 ( p < 0.05). The ICC values for the wearable system's repeated measurements of plantar pressure during walking ranged from 0.62 to 0.89 ( p < 0.05). Table 2. ICC values of the repeated measurements obtained from the wearable ultrasound imaging and sensing system during a gait cycle of the participated stroke survivors without and with AFO Gait cycle Paretic side without AFO Paretic side with AFO Thickness _MG Thickness _TA sMMG _MG sMMG _TA sEMG _MG sEMG _TA Plantar force Thickness _MG Thickness _TA sMMG _MG sMMG _TA sEMG _MG sEMG _TA Plantar force 0% 0.988 0.936 0.881 0.855 0.791 0.900 NA 0.951 0.989 0.637 0.810 0.716 0.657 NA 5% 0.974 0.950 0.677 0.643 0.706 0.803 0.816 0.935 0.991 0.651 0.806 0.771 0.704 0.843 10% 0.966 0.952 0.668 0.546 0.797 0.859 0.859 0.912 0.979 0.632 0.794 0.707 0.689 0.777 15% 0.950 0.931 0.771 0.621 0.759 0.710 0.888 0.901 0.984 0.746 0.828 0.68 0.833 0.770 20% 0.965 0.930 0.715 0.819 0.760 0.791 0.786 0.934 0.981 0.574 0.732 0.774 0.742 0.721 25% 0.956 0.944 0.525 0.632 0.795 0.679 0.814 0.925 0.980 0.615 0.619 0.824 0.880 0.762 30% 0.968 0.959 0.658 0.541 0.856 0.891 0.736 0.917 0.981 0.650 0.685 0.974 0.893 0.694 35% 0.97 0.956 0.733 0.661 0.938 0.652 0.662 0.921 0.985 0.391 0.629 0.638 0.860 0.742 40% 0.977 0.943 0.656 0.490 0.723 0.797 0.763 0.932 0.986 0.690 0.411 0.724 0.843 0.790 45% 0.975 0.957 0.523 0.582 0.741 0.693 0.854 0.912 0.986 0.591 0.604 0.820 0.878 0.794 50% 0.973 0.943 0.509 0.646 0.785 0.652 0.842 0.970 0.987 0.582 0.787 0.876 0.870 0.636 55% 0.975 0.948 0.642 0.568 0.699 0.440 0.630 0.919 0.986 0.653 0.771 0.860 0.947 0.623 60% 0.994 0.922 0.561 0.681 0.816 0.583 0.609 0.900 0.980 0.638 0.902 0.653 0.955 0.805 65% 0.967 0.899 0.520 0.688 0.827 0.702 0.623 0.880 0.988 0.751 0.816 0.620 0.871 0.718 70% 0.962 0.877 0.726 0.688 0.783 0.643 NA 0.957 0.986 0.811 0.814 0.771 0.752 NA 75% 0.957 0.876 0.794 0.613 0.802 0.628 NA 0.968 0.988 0.681 0.692 0.469 0.553 NA 80% 0.945 0.893 0.640 0.512 0.815 0.663 NA 0.982 0.982 0.637 0.406 0.859 0.577 NA 85% 0.966 0.887 0.715 0.637 0.937 0.524 NA 0.948 0.985 0.712 0.568 0.521 0.533 NA 90% 0.959 0.884 0.449 0.784 0.823 0.841 NA 0.936 0.989 0.733 0.745 0.883 0.587 NA 95% 0.970 0.891 0.498 0.804 0.725 0.870 NA 0.977 0.987 0.791 0.910 0.740 0.491 NA 100% 0.985 0.902 0.638 0.794 0.644 0.877 NA 0.975 0.986 0.623 0.670 0.830 0.652 NA Mean 0.969 0.923 0.643 0.662 0.787 0.724 0.760 0.936 0.985 0.657 0.719 0.748 0.751 0.744 SD 0.012 0.029 0.112 0.098 0.071 0.128 0.099 0.028 0.003 0.090 0.128 0.123 0.146 0.065 (Note: TA, tibialis anterior muscle; MG, medial gastrocnemius muscle; sEMG, surface electromyography; sMMG, surface mechanomyography; NA, not available; the green-highlighted cells indicate the existence of significance in ICC values (p < 0.05).) Muscle thickness Figures 1 A-B illustrate the average normalized thickness of the TA and MG muscles at the paretic side of participants during walking, both with and without the use of AFO. When wearing the AFO at the paretic side, the normalized TA muscle thickness significantly decreased during the MSt phase (20%-25% of a gait cycle) and significantly increased during the ISw phase (60%-65% of a gait cycle) ( p < 0.05). Conversely, when not wearing the AFO at the paretic side, the normalized TA muscle thickness significantly decreased during the LR phase (0%-5% of a gait cycle) and significantly increased during the PSw phase (55%-60% of a gait cycle) ( p < 0.05). Additionally, the normalized MG muscle thickness demonstrated significant changes during the LR, MSt, and TSt phases (0%-10%, 25%-30%, and 40%-45% of a gait cycle) while wearing the AFO ( p < 0.05), and only showed a significant increase during the TSt phase (35%-40% of a gait cycle) when not wearing the AFO ( p < 0.05). In the comparison of walking with and without AFO at the paretic side, the normalized TA muscle thickness appeared to be greater when wearing the AFO than when not wearing it throughout a gait cycle; however, this difference was not statistically significant ( p > 0.05, Figs. 1 A-B). In contrast, a consistently smaller normalized MG muscle thickness was observed when wearing the AFO comparing to not wearing it, with a significant 2.8%-4.0% reduction primarily observed during the MSt, TSt, and MSw phases (20%-35% and 70%-80% of a gait cycle, p < 0.05). Muscle electrical and mechanical activity Figures 1 C-F illustrate the average normalized sEMG and sMMG signals of the TA and MG muscles on the paretic side during waling in stroke participants, both without and with the use of an AFO. In relation to the TA muscle, a significant 10.1%-14.1% increase in the normalized sEMG signal was observed during the PSw and ISw phases (50%-65% of a cycle gait) when the AFO was utilized ( p < 0.05). Additionally, a significant 14.2% increase in normalized sMMG signal was noted during the LR phase (5% of a gait cycle) when the participants were walking with AFO ( p < 0.05). Concerning the MG muscle, a significant 8.5%-11.5% decrease in the normalized sEMG signal was observed during the ISw and MSw phases (65%-80% of a gait cycle) with AFO use ( p < 0.05). The normalized sMMG signal showed a significant increase (12.3%) during the LR phase (5% of a gait cycle) and a reduction (15.1%) during the MSt phase (20% of a gait cycle) when using the AFO ( p < 0.05). Figure 2 presents CI values of the TA and MG muscles at the paretic side in stroke participants, both without and with the use of AFO, across various gait phases. When walking without AFO, the CI ranged from 68–118%, and with AFO, it ranged from 71–93% throughout the gait cycle in stroke participants. The fluctuation decreased from 50–22% after the fittings of AFO. Additionally, significant difference in CI were observed between the MSt and TSt phases ( p < 0.05), TSt and ISw phases ( p < 0.05), and ISw and MSw phases ( p < 0.001) when walking without AFO. However, significant differences were only observed between the ISw and MSw phases ( p < 0.05), and MSw and TSw phases ( p < 0.05) when walking with AFO. Moreover, there were significant reductions (20.4% and 26.1%) in CI during the ISw and MSw phases when walking with AFO compared to walking without AFO ( p < 0.05). Plantar force Figures 3 A-D depict the distribution of plantar force across the full foot, heel, 1st MTH, and 5th MTH on the paretic side of stroke participants during the stance phase while walking both without and with the AFO. A significant increase (1.0-1.7 N/kg) in the plantar force of the full foot was noted throughout most of the stance phase (5%-50% of a gait cycle) when walking with the AFO compared to without it ( p < 0.05). In terms of the heel, the plantar force significantly increased (0.6–1.2 N/kg) during the LR phase (5%-10% of a gait cycle), but significantly decreased (0.2–0.3 N/kg) during the PSw phase (55%-60% of a gait cycle) when using the AFO compared to not using it ( p < 0.05). Additionally, when AFO was worn, a significant increase in plantar force was also found at the 1st MTH during the MSt and TSt phases (20%-30% and 45%-50% of a gait cycle) and 5th MTH during the MSt and TSt phases (15%-50% of a gait cycle), with an increase of 0.1–0.5 N/kg and 0.5-1.0 N/kg, respectively ( p < 0.05). Temporal gait parameters Table 3 displays the alterations of temporal gait parameters at the paretic side while stroke participants walking with and without AFO. When walking with AFO, the stroke participants exhibited a significant decrease in stride time, stance time, and swing time, compared to walking without AFO ( p < 0.001). Additionally, the proportion of the stance phase in a gait cycle significantly decreased, while the proportion of the swing phase significantly increased in stroke participants while walking with AFO ( p < 0.05). Table 3 Comparison of temporal gait parameters of stroke participants between walking without and with AFO at the paretic side (n = 20) Interventions Stance phase (s) Swing phase (s) Stride time (s) Stance phase (%) Swing phase (%) Without AFO 1.36 ± 0.60 0.66 ± 0.44 2.02 ± 0.19 67 ± 6 33 ± 6 With AFO 1.13 ± 0.32 0.65 ± 0.14 1.79 ± 0.44 63 ± 3 37 ± 3 p value < 0.001 < 0.001 < 0.001 0.018 0.018 (Note: s: second; data are presented as mean ± standard deviation) Discussion This study has investigated the effect of wearing solid AFO on the paretic TA and MG muscle contraction patterns during different gait phases in sub-acute stroke participants, by utilizing an innovative wearable ultrasound imaging and sensing system to thoroughly examine the internal activity and morphology of the TA and MG muscles in stroke survivors while walking with and without an AFO at the paretic side. The study results generally supported the hypothesis that solid AFO usage could positively affect the contraction patterns of paretic TA and MG muscles, as well as gait asymmetry and weight bearing, during walking in post-stroke patients. More detailed discussions can be found below. Test-retest reliability The wearable ultrasound imaging and sensing system has demonstrated good to excellent test-retest reliability in capturing the thickness, sEMG signal, and sMMG signal of TA and MG muscles, as well as the plantar pressure, at the paretic side during walking in stroke survivors, both with and without AFO. These ICC values have been generally comparable to those reported for healthy people [ 23 ] and stroke survivors [ 17 ]. Muscle thickness A consistently slight increase was observed in the paretic TA muscle thickness when AFO was used during walking in stroke participants. This increase may be contributed by the passively dorsiflexed ankle joint that maintained by the solid AFO in stroke participants, as compared to the original foot drop position (or plantarflexed ankle joint) while they were walking without AFO. Correspondingly and conversely, this study did observe a significant reduction in the MG muscle thickness while stroke participants were with AFO. This reduction could be due to the passive elongation of the MG muscle upon passively dorsiflexing the paretic ankle joint with an AFO, resulting in the decreased MG muscle thickness. Furthermore, the fluctuations in the MG muscle thickness throughout the gait cycle were more pronounced with the use of AFO compared to walking without AFO. The observed trend in muscle thickness variation with AFO application appears to align more closely with the patterns, particularly during the ISw and MSw phases, documented in healthy young adults by Ma et al.[ 23 ], contrasting with the patterns observed during walking without AFO. These results indicate that the utilization of AFO may facilitate a more natural contraction of the paretic MG muscle during walking in stroke survivors. Further research could involve the development and application of wearable ultrasound imaging systems with enhanced imaging quality, capable of visualizing muscle fascicle length and pennation angle, to validate these observations. Muscle electrical activity This study has observed the generally similar paretic TA sEMG trend during walking in stroke patients, regardless of with and without AFO, as that of a previous study reporting stroke survivors’ muscle activity during natural walking [ 17 ]. The observed increased paretic TA sEMG signal when using AFOs may suggest that the AFO could facilitate the TA muscle contraction during the stance phase. This study has also observed that the use of AFO could significantly increase the TA muscle activity during ISw phase. This contradicted the previously reported finding of using AFO could decline TA muscle contraction during the swing phase, since the AFO could help maintain ankle joint in a neutral position, which may suppress the users from actively contracting the TA muscles by themselves [ 13 , 14 ]. This inconsistency may be attributed to the walking training that the participants underwent with the AFO prior to the walking trials in this study, in which all stroke participants were guided to engage the TA and MG muscles while walking with AFO by an experienced physiotherapist. This suggests that appropriate walking training with AFO in stroke patients may help to stimulate TA muscle activity during walking. This finding warrants further investigation in the long term. Aligning with the decreased thickness of the MG muscle, this study also observed significant reductions in MG sEMG signals during Isw and MSw phases while stroke participants walking with AFO compared to without AFO. This study also observed that MG muscle thickness significantly decreased during the MSw phase, while MG sEMG signals significantly decreased during Isw and MSw phases. This may be explained by delays in MG muscle activity where the timing of muscle sEMG signal generation was commonly earlier than that of muscle internal morphological contraction [ 30 ]. It is also noteworthy to observe that significant differences in MG thickness were observed between two conditions of with and without AFO during MSt and TSt phases when analyzing ultrasound images. However, no significant difference was found in the MG sEMG signal during these two phases. Similarly, Choo et al. has utilized ultrasound imaging to detect the oropharyngeal swallowing events, and demonstrated its ability to further accurately capture the tongue base retraction and hyolaryngeal excursion during swallowing in young adults, which could not be detected using the sEMG electrodes [ 31 ]. These results imply that ultrasound imaging could perform more effectively when capturing the internal morphological changes in muscles during dynamic activities; while the sEMG has been limited to detecting the muscle electrical activity from the skin surface, which may introduce more noise and crosstalk among neighboring muscles. This underscores the potential benefits of integrating both ultrasound imaging and sEMG measurements in future studies to gain a more comprehensive understanding of the lower-limb muscle activity across different dynamic conditions in participants. The significantly smaller CI values observed in the paretic TA and MG muscles during Isw and MSw phases suggest an improved co-contraction pattern between these two antagonist and agonist ankle muscles. This improved co-contraction may facilitate better ankle control and reduced energy expenditure during the ISw and MSw phases in the sub-acute stroke patients walking with AFO compared to walking without AFO [ 15 ]. The reduced CI values may be contributed by the more natural contraction of the paretic MG muscle during these two phases when using the AFO, as supported by the documented thickness of the paretic MG muscle documented in this study. Additionally, the overall reduced variability in CI values (i.e., reduced from 50–22%) observed throughout a gait cycle may indicate a more stable co-contraction of the TA and MG muscles when using AFO. This increased stability in co-contraction may also contribute to a reduction in energy consumption during walking. Nevertheless, further research is needed to confirm these intriguing findings. Plantar force and gait cycle By controlling the abnormal foot drop and plantar flexion using an AFO at the paretic side, the weight-bearing capacity of the paretic side during stance phase has significantly increased in stroke participants in this study. Additionally, it has also allowed the paretic ankle joint to adapt and accept loading more quickly during the loading response phase, and thereby reducing the time spent in the stance phase in stroke participants. Consequently, the proportions of the stance and swing phases in the gait cycle has improved, leading to a more symmetrical gait pattern and increased walking speed in stroke survivors using AFO. Such findings of this study have also been in accordance with the findings reported in previous studies [ 12 , 32 ]. Limitations Several limitations should be acknowledged when interpreting the findings of this pilot study. The lack of the comparison between the paretic and nonparetic sides made it difficult to determine how the use of AFO at the paretic side affected the performance of the nonparetic side during walking in stroke survivors. Given the impaired function at the paretic side, the nonparetic side may have some compensations during walking as reported in previous studies [ 33 ]. Furthermore, it is important to note that only the immediate impact of AFO use on the thickness and activity of the TA and MG muscles was examined in this pilot study, future studies shall also look into the long-term effects. Conclusions The results of this pilot study generally supported that the use of AFO could positively affect the contraction patterns of the paretic TA and MG muscles, as well as weight-bearing capacity and gait symmetry, during walking in the sub-acute stroke patients. However, future research is still needed to understand the long-term effects of AFO use in stroke patients. Declarations Authors’ contributions: W.L. and H.-D.W. contributed to the conception, study design, data acquisition, analysis and interpretation, and draft of the manuscript. Y.-Y.L. contributed to the data acquisition, software development, data analysis and interpretation, and editing of the manuscript. R.T-L.Z. and Y.-Y.L. contributed to data analysis and editing of the manuscript. Y.T.L., L.-K.W., and J.-F.W. contributed to the hardware development, software development, and editing of the manuscript. Y-P.Z. contributed to the hardware and software development and editing of the manuscript. C.Z-H.M. contributed to conception, study design, funding acquisition, data analysis and interpretation, project supervision, and editing of the manuscript. All authors have read and agreed to the published version of the manuscript. Competing interests : The authors declare no competing interests. Data availability: Data will be made available upon reasonable request from the corresponding author ( [email protected] ). Trial registration: Ref: ChiCTR2300074539; registration date: 09/08/2023; URL: https://www.chictr.org.cn/showproj.html?proj=203348 Ethics declarations : The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Kunming Medical University Medical Ethics Committee (Ref: KMMU2023MEC149; date of approval: 23 May 2023). Informed consent was obtained from all subjects involved in the study. Funding resources: This research was partially supported by the Research Institute for Smart Ageing (RISA), The Hong Kong Polytechnic University (Ref: P0038945); Department of Biomedical Engineering, The Hong Kong Polytechnic University (Ref: 9BH7). References Laufer, Y.;Hausdorff, J. M. & Ring, H. Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity. Am. J. Phys. Med. 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L. & Patten, C. Electromyography Exposes Heterogeneity in Muscle Co-Contraction following Stroke. Front. Neurol. 8, 699 (2017). Swank, C.;Almutairi, S.;Wang Price, S. & Gao, F. Immediate kinematic and muscle activity changes after a single robotic exoskeleton walking session post-stroke. Top. Stroke Rehabil. 27, 503–515 (2020). Lyu, P. Z.;Zhu, R. T. L.;Ling, Y. T.;Wang, L. K.;Zheng, Y. P. & Ma, C. Z. H. How Paretic and Non-Paretic Ankle Muscles Contract during Walking in Stroke Survivors: New Insight Using Novel Wearable Ultrasound Imaging and Sensing Technology. Biosensors 12, 349 (2022). Ramsay, J. W.;Barrance, P. J.;Buchanan, T. S. & Higginson, J. S. Paretic muscle atrophy and non-contractile tissue content in individual muscles of the post-stroke lower extremity. J. Biomech. 44, 2741–2476 (2011). Nordez, A.;Jolivet, E.;Sudhoff, I.;Bonneau, D.;de Guise, J. A. & Skalli, W. Comparison of methods to assess quadriceps muscle volume using magnetic resonance imaging. J. Magn. Reson. 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The Brunnstrom Stages of Stroke Recovery , (2022). Aboubakr, S.;Abu-Ghosh, A.;Ackley, W. B.;Adolphe, T. S.;Aeby, T. C.;Aeddula, N. R.;Agadi, S. & Agasthi, P. in StatPearls [Internet] (eds Andrew Harb & Stephen Kishner) (StatPearls Publishing, 2023). Downs, S. The Berg Balance Scale. J. Physiother. 61, 46 (2015). Blum, L. & Korner-Bitensky, N. Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys. Ther. 88, 559–566 (2008). Lyu, P. Z.;Zhu, R. T.;Ling, Y. T.;Wang, L. K.;Zheng, Y. P. & Ma, C. Z. How Paretic and Non-Paretic Ankle Muscles Contract during Walking in Stroke Survivors: New Insight Using Novel Wearable Ultrasound Imaging and Sensing Technology. Biosensors (Basel) 12, (2022). Rancho Los Amigos Medical Center, P. S., Rancho Los Amigos Medical Center Physical Therapy Dept. Observational Gait Analysis . (Los Amigos Research and Education Institute, Rancho Los Amigos National Rehabilitation Center, 2001). Ling, Y. T.;Ma, C. Z.-H.;Shea, Q. T. K. & Zheng, Y.-P. Sonomechanomyography (SMMG): Mapping of Skeletal Muscle Motion Onset during Contraction Using Ultrafast Ultrasound Imaging and Multiple Motion Sensors. Sensors 20, 5513 (2020). Choo, H.;Kwong, E.;Shek, P. T.-C.;Leung, M.-T.;Zheng, Y.-P. & Lam, W. Y. S. Temporal measures of oropharyngeal swallowing events identified using ultrasound imaging in healthy young adults. Plos One 17, e0270704 (2022). Prenton, S.;Hollands, K.;Kenney, L. & Onmanee, P. Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research. J. Rehabil. Med. 50, 129–139 (2018). Ma, C. Z.-H.;Zheng, Y.-P. & Lee, W. C.-C. Changes in gait and plantar foot loading upon using vibrotactile wearable biofeedback system in patients with stroke. Topics in Stroke Rehabilitation 25, 20–27 (2018). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4217969","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":296747600,"identity":"fd4a3062-5457-4655-bbb4-0582ac7c791f","order_by":0,"name":"Wei Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBACfmbGhgMfKmzkGNgbkIQfALEBD3Ytku3MjQdnnEkzZuA5ABEBK0zAo8XgPHvzYd62w4kNEglEamE4zNgAtOUw4/aZjx8+LtxhI2/PwHvwQWLbYQZzmL1ogLEZ7Jd0ZpnbacbGM8+kGfYw8CUbgLRY9jZg1cLMDLbFmk1COodNGujCBB4GHjMJkBaD89jdxQbUAvQLM4+E5BmQlv+EtfBAtDhLSEjwgLQcQNJyFrvDJCAOSzOQ4AH6hbct2bDnMNAvCefSeQzOYPe+/fnjjz8Ao7J+Bvvhh4952+zk2dt7Dz74UGYtZ3AmAbvLsIQIMD4Y2RhwxQp2/wHxH1I0jIJRMApGwTAHAPX3XWJJsdRsAAAAAElFTkSuQmCC","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Liu","suffix":""},{"id":296747602,"identity":"21edb0b7-ce2e-4085-b9b2-149bb386827d","order_by":1,"name":"Hui-Dong Wu","email":"","orcid":"","institution":"Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hui-Dong","middleName":"","lastName":"Wu","suffix":""},{"id":296747603,"identity":"6dbbd8df-39c0-44fe-aba5-9957e65f7bd9","order_by":2,"name":"Yu-Ying Li","email":"","orcid":"","institution":"Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu-Ying","middleName":"","lastName":"Li","suffix":""},{"id":296747604,"identity":"17acfd0d-402c-40a4-ba15-a485f7f7633c","order_by":3,"name":"Ringo Tang-Long Zhu","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Ringo","middleName":"Tang-Long","lastName":"Zhu","suffix":""},{"id":296747605,"identity":"79bb0e71-a2e1-4e19-ba3d-abd4b72ba97c","order_by":4,"name":"Yu-Yan Luo","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Yu-Yan","middleName":"","lastName":"Luo","suffix":""},{"id":296747606,"identity":"5b47bb2c-86cc-44cb-b15c-5fc3803b415b","order_by":5,"name":"Yan To Ling","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"To","lastName":"Ling","suffix":""},{"id":296747607,"identity":"cb99780f-528f-4846-9a7c-8a198f8909ea","order_by":6,"name":"Li-Ke Wang","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Li-Ke","middleName":"","lastName":"Wang","suffix":""},{"id":296747608,"identity":"500d4340-57dc-4914-ae56-80ff95c79f0a","order_by":7,"name":"Jian-Fa Wang","email":"","orcid":"","institution":"Beijing Sonoptek Co.Ltd","correspondingAuthor":false,"prefix":"","firstName":"Jian-Fa","middleName":"","lastName":"Wang","suffix":""},{"id":296747609,"identity":"f519d10e-8eae-4cba-b01d-cc049d89db93","order_by":8,"name":"Yong-Ping Zheng","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Yong-Ping","middleName":"","lastName":"Zheng","suffix":""},{"id":296747610,"identity":"3b857c61-b819-4465-9a2e-5c7858d5d0dc","order_by":9,"name":"Christina Zong-Hao Ma","email":"","orcid":"","institution":"The Hong Kong Polytechnic University","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"Zong-Hao","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2024-04-04 12:42:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4217969/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4217969/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55769338,"identity":"2a21529c-3d2b-4618-bd8e-d380b819c5aa","added_by":"auto","created_at":"2024-05-02 20:42:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":221065,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in average normalized thickness, sEMG, and sMMG of the TA and MG muscles of the paretic side during a gait cycle, while the stroke participants walking without and with AFO. (Note: the solid lines and dashed lines represent the mean and mean ± standard deviation of each average measurement, respectively; TA, tibialis anterior muscle; MG, medial head of gastrocnemius muscle; sEMG, surface electromyography; sMMG, surface mechanomyography; LR, loading response; MSt, mid-stance; TSt, terminal stance; PSw, pre-swing; ISw, initial swing, MSw, mid-swing; TSw, terminal swing.)\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4217969/v1/dc0a19ccaa7ebc8afb3e5bc5.jpg"},{"id":55769836,"identity":"85618337-ba0e-4b39-afc5-d80fe182b8b4","added_by":"auto","created_at":"2024-05-02 20:50:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41374,"visible":true,"origin":"","legend":"\u003cp\u003eCo-contraction index (CI) of TA and MG muscles of the paretic side during different gait phases while stroke participants walking without and with AFO. (Note: AFO, ankle-foot orthosis; LR, loading response; MSt, mid-stance; TSt, terminal stance; Isw, initial swing, MSw, mid-swing; TSw, terminal swing.)\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4217969/v1/1943d207f25b5aa2d7757f4a.jpg"},{"id":55769336,"identity":"07d42eff-7433-4b1f-bf80-23a57344832e","added_by":"auto","created_at":"2024-05-02 20:42:03","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":140104,"visible":true,"origin":"","legend":"\u003cp\u003ePlantar force of the full foot, heel, 1\u003csup\u003est\u003c/sup\u003e MTH, and 5\u003csup\u003eth\u003c/sup\u003e MTH of stroke participants while walking without and with AFO (n=20). (Note: AFO, ankle-foot orthosis; MTH, metatarsal head; LR, loading response; MSt, mid-stance; TSt, terminal stance; PSw, pre-swing; Isw, initial swing, MSw, mid-swing; TSw, terminal swing.)\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4217969/v1/cb7904c1036e72fa8003d5aa.jpg"},{"id":64634605,"identity":"710828a5-69f6-4e80-baaa-3fd758faf11e","added_by":"auto","created_at":"2024-09-16 22:23:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1232873,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4217969/v1/eafb9cb9-7b8e-4c6f-b1cc-f8243244059c.pdf"},{"id":55769339,"identity":"0775227f-18b4-4fcf-98ba-a4e7204dfdf5","added_by":"auto","created_at":"2024-05-02 20:42:03","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1511955,"visible":true,"origin":"","legend":"","description":"","filename":"GraphicalAbstract.png","url":"https://assets-eu.researchsquare.com/files/rs-4217969/v1/6e024ab0e5a92a4d23215538.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of ankle-foot orthosis on paretic gastrocnemius and tibialis anterior muscles contraction of stroke survivors during walking: a pilot study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFoot drop is a prevalent and debilitating condition that often appears following a stroke. It is characterized by weakened or absent voluntary ankle dorsiflexion and a dragging or slapping gait pattern. This issue can result in diminished balance and mobility [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], as well as an elevated risk of falls [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. As a result, individuals who have had a stroke may experience restrictions in their daily activities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and a lower quality of life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The primary cause of foot drop after a stroke is typically associated with muscle weakness or paralysis in the ankle dorsiflexors, often accompanied by high muscle tone and possible contracture in ankle plantar flexors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are various treatment options available to manage foot drop and improve functional outcomes following a stroke. Physical therapy plays a crucial role in rehabilitation, focusing on strengthening the affected/paretic muscles, improving balance and coordination, and retraining the affected muscles to regain control and function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Besides physical therapies, certain assistive devices such as an ankle-foot orthosis (AFO) can provide stability and prevent foot drop by maintaining the foot in a neutral or slightly dorsiflexed position [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This helps to enhance foot clearance while walking and reduces the risk of falls in stroke patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnderstanding more on the changes in paretic ankle muscle activity while wearing AFOs could offer more evidence for future clinical practice. Previous research has demonstrated that AFOs can promptly enhance an individual's walking speed, balance, energy expenditure, and overall gait biomechanics [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, their effect on the muscle activity of dorsiflexors and plantar flexors of the paretic side in post-stroke patients has remained inconsistent and unconcluded. Murayama and Yamamoto have utilized surface electromyography (sEMG) to monitor tibialis anterior (TA) and soleus (SOL) muscles\u0026rsquo; activity during walking and discovered that the plantarflexion movement reduced by AFO can augment the activity of TA muscle during the loading response phase and the activity of the SOL muscle during the stance phase, resulting in improved stability and propulsion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Meanwhile, traditional treatment approaches may sometimes avoid the use of AFO due to concerns about possible disuse atrophy of the TA muscle [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], as immobilization by AFO could inhibit the eccentric contraction of the TA muscle during walking. Some previous studies have indicated that individuals using AFO exhibited reduced sEMG activity of the TA muscle from the swing to the loading response phase, compared to those walking without AFO [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This implies the risk of TA muscle disuse atrophy with prolonged AFO use. In contrast, Nikamp et al. have noted that although a more pronounced decrease in sEMG activity of the TA muscle was observed in individuals with AFO compared to those without AFO in the early stages of treatment, this difference disappeared after 26 weeks [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, it is essential to further explore the impact of using AFO on the paretic ankle dorsiflexors and plantar flexors in stroke survivors, particularly with the potential application of more advanced technologies.\u003c/p\u003e \u003cp\u003eA variety of sensors and tools have been employed to study and assess muscle activity in different conditions. Among them, sEMG can detect the electrical signals of a muscle, while surface mechanomyography (sMMG) sensors can measure the mechanical activities of a muscle, both from the skin surface in stroke survivors [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This enhances our understanding of muscle performance and the underlying mechanisms of muscle adaptations during various treatments or interventions. Concurrently, imaging techniques have been used to visualize the internal structure and morphology of muscles, aiding in the assessment of muscle atrophy post-stroke. Magnetic resonance imaging (MRI) can quantify parameters related to skeletal muscle quantity, such as muscle volume and cross-sectional area [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, its clinical application for post-stroke muscle assessment is relatively limited due to high costs, time consumption, and labor intensity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], as well as challenges in dynamic settings. Ultrasound imaging has gained attention for its ability to non-invasively and affordably assess muscles' internal morphology without ionizing radiation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Monjo et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and Gonzalez-Buonomo et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] have utilized ultrasound imaging and observed reduced muscle thickness in the paretic lower extremity of post-stroke individuals. Nevertheless, previous technical constraints restricted these technologies to evaluating muscle contraction patterns and internal morphological changes only in static conditions (i.e., recumbent [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] or sitting [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] position) among participants.\u003c/p\u003e \u003cp\u003eTo understand the lower-extremity muscles' activity and internal morphology during dynamic or walking conditions, a wearable ultrasound imaging and sensing system has been developed in our previous work. This system consisted of a wearable ultrasound probe and multiple motion sensors to simultaneously measure the muscle's ultrasound image, muscle sEMG and sMMG activity, and the plantar force during walking [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It has been applied in healthy young adults and post-stroke individuals to capture their ankle muscle activity during natural walking without any interventions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the changes in ankle muscle activity in post-stroke individuals while walking with AFO have remained unclear and merits further study.\u003c/p\u003e \u003cp\u003eTo address the research gaps mentioned earlier, this study utilized the innovative wearable ultrasound imaging and sensing system to comprehensively examine the impact of wearing a solid AFO on the internal contraction patterns and morphological variations of stroke survivors' TA and medial gastrocnemius (MG) muscles during walking. It was hypothesized that the use of AFO would positively influence the contraction patterns of the TA and MG muscles among post-stroke participants. The findings could provide valuable insights for the orthotic management of foot drop in stroke survivors and enhance the evidence-based practice in the future.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants should meet the following inclusion criteria: (1) first stroke episode within 6 months; (2) hemiparesis due to unilateral ischemic or hemorrhagic stroke; (3) ability to walk at least eight meters without assistance; (4) passive ankle dorsiflexion range of motion of at least 0\u0026deg; (i.e., the neutral position). Patients were excluded if they had (1) cognitive impairment, (2) uncontrolled cardiovascular or respiratory disorders, or (3) fracture or muscle disorders affecting mobility. Informed consent forms were signed once the eligible patients agreed to participate in this study. This study was approved by Chinese Clinical Trial Registry (Ref: ChiCTR2300074539). Ethical approval was granted by Kunming Medical University Medical Ethics Committee (Ref: KMMU2023MEC149) and all procedures were conducted in accordance with the Helsinki Declaration of 1975.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eWearable ultrasound imaging and sensing system\u003c/h2\u003e \u003cp\u003eAs detailed previously [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the wearable system included a wearable ultrasound probe (band width: 7.5 MHz\u0026thinsp;\u0026plusmn;\u0026thinsp;35%, frame rate: 10 Hz), two sets of sEMG electrodes (272-Bx, Noraxon USA Inc, Scottsdale, AZ, USA), an sMMG sensor (N1000060, VTI Technologies Oy, Vantaa, Finland), and three thin-film force sensors (A301, Tekscan Co., Ltd., South Boston, MA, USA). These components were utilized to capture the muscle's real-time B-mode ultrasound image, electrical activity, mechanical activity, and the plantar force for identifying gait cycles [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExperimental procedure\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSubjective assessments were firstly conducted for each participant. A comprehensive description of the experimental procedures was given. The participant\u0026rsquo;s stage of stroke recovery was assessed using the Brunnstrom Approach [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], muscle tone of plantar flexors at the paretic side was assessed using the Modified Ashworth Scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and balance performance was assessed using the Berg Balance Scale [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] in accordance with the established protocols [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThen each participant accomplished the instrumented walking trials with the wearable ultrasound imaging and sensing system placed on the paretic side. Before the walking trials, ultrasound images of the paretic MG and TA muscles were captured separately for each participant in a comfortable standing position. These images served as the baseline thickness measurements for the study. The participant was then equipped with a prefabricated solid posterior leaf-spring AFO (272-Bx, Noraxon USA Inc, Scottsdale, AZ, USA), following the manufacturer\u0026rsquo;s instructions. The participant was directed to walk approximately twenty meters to acclimate to the AFO, during which he/she was instructed to activate the paretic TA and MG muscles while walking with the AFO. Subsequently, the participant was fitted with the wearable ultrasound imaging and sensing system. The ultrasound probe was positioned longitudinally on the paretic MG muscle belly, with one set of sEMG electrodes and the sMMG sensor placed parallel to the ultrasound probe on the paretic MG muscle belly. Another set of sEMG electrodes was positioned on the paretic TA muscle. Additionally, three thin-film force sensors were placed underneath the first and fifth metatarsal heads (1st and 5th MTH) and the heel of the paretic foot. Once properly set up, the participant was instructed to walk three consecutive trials on flat ground at a comfortable speed, with each trial covering approximately eight meters. The same procedures were repeated to evaluate the paretic MG muscle activity while walking without an AFO, and the paretic TA muscle activity while walking with and without an AFO [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The sequence for capturing the TA and MG muscles activity with and without wearing the AFO was randomized for each participant.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData processing and analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFor each walking condition, three complete gait cycles were extracted from the middle portion of each of the three walking trials for further processing using MATLAB (Version 2016b, The MathWorks Inc, Natick, MA, USA). To ensure consistency, all data were resampled to represent the 0-100% gait cycle with a 5% interval [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Each gait cycle was divided into seven phases: loading response (LR, 0\u0026ndash;10%), mid-stance (MSt, 10%-30%), terminal stance (TSt, 30%-50%), pre-swing (PSw, 50%-60%), initial swing (ISw, 60%-70%), mid-swing (MSw, 70%-85%), and terminal swing (TSw, 85%-100%) phases [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003esMMG and sEMG signal processing and analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe sMMG and sEMG data were filtered using a fourth-order Butterworth band-pass filter (5\u0026ndash;50 Hz for MMG and 30\u0026ndash;500 Hz for EMG), followed by rectification and additional filtering with a moving-average filter using a temporal window of 0.101 seconds. The data were then normalized to the peak values that observed within the three extracted gait cycles [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The mean amplitude value of the processed signal within each 5% interval of a gait cycle was used for further analysis.\u003c/p\u003e \u003cp\u003eBesides, concerning the sEMG data, the co-contraction index (CI) was examined to measure the co-contraction pattern of TA and MG muscles in various gait phases while walking. In the LR, ISw, MSw, and TSw phases, the TA muscle functioned as the agonist muscle, whereas the MG muscle functioned as the antagonist muscle [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Thus, the CI was determined as [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cspan class=\"InlineEquation\"\u003e \u003cspan class=\"mathinline\"\u003e\\(\\text{C}\\text{I}=\\frac{2{\\text{I}}_{\\text{M}\\text{G}}}{{\\text{I}}_{\\text{M}\\text{G}}+{\\text{I}}_{\\text{T}\\text{A}}}\\)\u003c/span\u003e \u003c/span\u003e*100(1)\u003c/p\u003e \u003cp\u003eIn the MSt and TSt phases, the MG muscle was anticipated to be the agonist muscle, while the TA muscle was expected to be the antagonist muscle [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Hence, the CI was computed as follows [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cspan class=\"InlineEquation\"\u003e \u003cspan class=\"mathinline\"\u003e\\(\\text{C}\\text{I}=\\frac{2{\\text{I}}_{\\text{T}\\text{A}}}{{\\text{I}}_{\\text{M}\\text{G}}+{\\text{I}}_{\\text{T}\\text{A}}}\\)\u003c/span\u003e \u003c/span\u003e*100(2)\u003c/p\u003e \u003cp\u003eIn Equations (1) and (2), I\u003csub\u003eMG\u003c/sub\u003e was calculated as the integral area under the curve that created by the normalized sEMG signal of the MG muscle, while I\u003csub\u003eTA\u003c/sub\u003e was calculated as the integral area under the curve that created by the normalized sEMG signal of the TA muscle, during the corresponding phases. The CI was calculated for each gait phase, except for the PSw phase, as the roles of TA and MG muscles as agonist and antagonist were reversed during this phase [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUltrasound image processing and analyses\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA skilled practitioner manually annotated all the muscle ultrasound imaging data by marking the upper and lower muscle boundaries on each extracted ultrasound imaging frame post-experiment. A custom MATLAB algorithm was utilized to determine the muscle area by measuring the area between the marked upper and lower muscle boundaries on each ultrasound imaging frame. The muscle area was then divided by the width of the ultrasound image (30 mm) to calculate the average muscle thickness for each ultrasound image. The average muscle thickness values from three consecutive baseline ultrasound images, captured while the participant's ankle joint was in a comfortable standing position, were averaged to establish the baseline muscle thickness. This baseline thickness was considered as the reference value and set as \"100%\" during the normalization process. To normalize the ultrasound imaging data, the average muscle thickness of each ultrasound imaging frame was divided by the baseline muscle thickness first and then multiplied by 100%, resulting in the normalized average muscle thickness in percentage. The mean of such normalized thickness values within each 5% interval of a gait cycle was utilized for further statistical analyses [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStatistical analyses were conducted using SPSS 25.0 software, with a significance level set at 0.05. The test-retest reliability of the collected data across three repetitive gait cycles for each walking condition was assessed using the intraclass correlation coefficient (ICC). The paired t-test was used to compare the differences in normalized muscle thickness, sEMG, sMMG, and plantar force of the paretic side among participants with and without the use of AFO during walking.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDemographics and subjective assessment results\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a total of 20 sub-acute stroke survivors (13 males and 7 females) were recruited from three hospitals in Yunnan province, China. The average age of the participants was 53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3 years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation), and their average body mass index (BMI) was 24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7. All participants were within 1 to 6 months post-stroke, with Brunnstrom Scale ranging from III to VI. The muscle tone of the plantar flexors, assessed by the Modified Ashworth Scale, was 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3; and the Berg Balance Scale Score was 35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of stroke participants (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e(M/F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCause of stroke\u003c/p\u003e \u003cp\u003e(hemorrhagic/ Ischemic)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBrannstrom Scale (III/IV/V/VI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMonths since stroke\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eParetic leg (L/R)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModified Ashworth Scale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBBS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e \u003cp\u003e(range: 39.0\u0026ndash;68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003cp\u003e(range: 18.7\u0026ndash;29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9/8/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003cp\u003e(range: 1.0\u0026ndash;6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003cp\u003e(range: 0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003cp\u003e(range: 29.0\u0026ndash;53.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e(Note: M/F: male/female; BMI: body mass index; L/R: left/right; Modified Ashworth Scale: the tone of gastrocnemius muscle on the paretic side; BBS: Berg Balance Scale; data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and range.)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTest\u0026ndash;retest reliability\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays the ICC values for various parameters, including muscle thickness, sEMG signal, sMMG signal, and plantar force within each 5% interval of a gait cycle for different walking conditions. The test-retest reliability of the wearable system for measuring TA and MG muscle thickness remained consistent among participants, regardless of AFO usage, with ICC values ranging from 0.880 to 0.991 (TA) and 0.876 to 0.994 (MG), respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For the sEMG signals of the MG and TA muscles, most ICC values exceeded 0.70, with a small portion ranging from 0.46 to 0.70 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The ICC values for the sMMG signals of the TA and MG muscles were relatively lower and more variable, with most values falling between 0.61 and 0.88, and a few between 0.39 and 0.59 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The ICC values for the wearable system's repeated measurements of plantar pressure during walking ranged from 0.62 to 0.89 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003ctable style=\"width: 7.2e+2pt;border: none;border-collapse:collapse;\"\u003e\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eICC values of the repeated measurements obtained from the wearable ultrasound imaging and sensing system during a gait cycle of the participated stroke survivors without and with AFO\u003c/p\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:40.55pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:9.3pt;\"\u003e\n \u003cp style='margin:0in;text-align:justify;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eGait cycle\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width:340.9pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:9.3pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:18.05pt;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eParetic side without AFO\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width:340.85pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:9.3pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:18.05pt;'\u003e\u003cstrong\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eParetic side with AFO\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eThickness _MG\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eThickness _TA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esMMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_MG\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esMMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_TA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esEMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_MG\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esEMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_TA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003ePlantar\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eforce\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eThickness\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_MG\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eThickness\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:center;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_TA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esMMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_MG\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esMMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e_TA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.1pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003esEMG\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times 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style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003ePlantar\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eforce\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\"\u003e\n \u003cp style='margin:0in;text-align:justify;line-height:13.0pt;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:40.55pt;padding:0in 0in 0in 0in;height: 6.0pt;\"\u003e\n \u003cp 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0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003eSD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.012\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.029\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.112\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.098\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.071\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.099\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.028\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.003\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.090\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.123\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.7pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.146\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:48.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 0in 0in 0in;height:23.95pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e0.065\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;\"\u003e\n \u003cp style='margin:0in;text-align:justify;line-height:13.0pt;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"16\" style=\"width:722.4pt;border:none;padding:0in 0in 0in 0in;height:21.2pt;\"\u003e\n \u003cp style='margin:0in;text-align:left;line-height:normal;font-size:13px;font-family:\"Palatino Linotype\",serif;color:black;text-indent:.25in;'\u003e\u003cspan style='font-size:12px;font-family:\"Times New Roman\",serif;color:windowtext;'\u003e(Note: TA, tibialis anterior muscle; MG, medial gastrocnemius muscle; sEMG, surface electromyography; sMMG, surface mechanomyography; NA, not available; the green-highlighted cells indicate the existence of significance in ICC values (p \u0026lt; 0.05).)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n\u003c/table\u003e\u003cbr\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMuscle thickness\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-B illustrate the average normalized thickness of the TA and MG muscles at the paretic side of participants during walking, both with and without the use of AFO. When wearing the AFO at the paretic side, the normalized TA muscle thickness significantly decreased during the MSt phase (20%-25% of a gait cycle) and significantly increased during the ISw phase (60%-65% of a gait cycle) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Conversely, when not wearing the AFO at the paretic side, the normalized TA muscle thickness significantly decreased during the LR phase (0%-5% of a gait cycle) and significantly increased during the PSw phase (55%-60% of a gait cycle) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the normalized MG muscle thickness demonstrated significant changes during the LR, MSt, and TSt phases (0%-10%, 25%-30%, and 40%-45% of a gait cycle) while wearing the AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and only showed a significant increase during the TSt phase (35%-40% of a gait cycle) when not wearing the AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the comparison of walking with and without AFO at the paretic side, the normalized TA muscle thickness appeared to be greater when wearing the AFO than when not wearing it throughout a gait cycle; however, this difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-B). In contrast, a consistently smaller normalized MG muscle thickness was observed when wearing the AFO comparing to not wearing it, with a significant 2.8%-4.0% reduction primarily observed during the MSt, TSt, and MSw phases (20%-35% and 70%-80% of a gait cycle, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMuscle electrical and mechanical activity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC-F illustrate the average normalized sEMG and sMMG signals of the TA and MG muscles on the paretic side during waling in stroke participants, both without and with the use of an AFO. In relation to the TA muscle, a significant 10.1%-14.1% increase in the normalized sEMG signal was observed during the PSw and ISw phases (50%-65% of a cycle gait) when the AFO was utilized (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, a significant 14.2% increase in normalized sMMG signal was noted during the LR phase (5% of a gait cycle) when the participants were walking with AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Concerning the MG muscle, a significant 8.5%-11.5% decrease in the normalized sEMG signal was observed during the ISw and MSw phases (65%-80% of a gait cycle) with AFO use (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The normalized sMMG signal showed a significant increase (12.3%) during the LR phase (5% of a gait cycle) and a reduction (15.1%) during the MSt phase (20% of a gait cycle) when using the AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents CI values of the TA and MG muscles at the paretic side in stroke participants, both without and with the use of AFO, across various gait phases. When walking without AFO, the CI ranged from 68\u0026ndash;118%, and with AFO, it ranged from 71\u0026ndash;93% throughout the gait cycle in stroke participants. The fluctuation decreased from 50\u0026ndash;22% after the fittings of AFO. Additionally, significant difference in CI were observed between the MSt and TSt phases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), TSt and ISw phases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and ISw and MSw phases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) when walking without AFO. However, significant differences were only observed between the ISw and MSw phases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and MSw and TSw phases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) when walking with AFO. Moreover, there were significant reductions (20.4% and 26.1%) in CI during the ISw and MSw phases when walking with AFO compared to walking without AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePlantar force\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-D depict the distribution of plantar force across the full foot, heel, 1st MTH, and 5th MTH on the paretic side of stroke participants during the stance phase while walking both without and with the AFO. A significant increase (1.0-1.7 N/kg) in the plantar force of the full foot was noted throughout most of the stance phase (5%-50% of a gait cycle) when walking with the AFO compared to without it (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In terms of the heel, the plantar force significantly increased (0.6\u0026ndash;1.2 N/kg) during the LR phase (5%-10% of a gait cycle), but significantly decreased (0.2\u0026ndash;0.3 N/kg) during the PSw phase (55%-60% of a gait cycle) when using the AFO compared to not using it (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, when AFO was worn, a significant increase in plantar force was also found at the 1st MTH during the MSt and TSt phases (20%-30% and 45%-50% of a gait cycle) and 5th MTH during the MSt and TSt phases (15%-50% of a gait cycle), with an increase of 0.1\u0026ndash;0.5 N/kg and 0.5-1.0 N/kg, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTemporal gait parameters\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the alterations of temporal gait parameters at the paretic side while stroke participants walking with and without AFO. When walking with AFO, the stroke participants exhibited a significant decrease in stride time, stance time, and swing time, compared to walking without AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, the proportion of the stance phase in a gait cycle significantly decreased, while the proportion of the swing phase significantly increased in stroke participants while walking with AFO (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of temporal gait parameters of stroke participants between walking without and with AFO at the paretic side (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStance phase\u003c/p\u003e \u003cp\u003e(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSwing phase\u003c/p\u003e \u003cp\u003e(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStride time\u003c/p\u003e \u003cp\u003e(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStance phase\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSwing phase\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithout AFO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith AFO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e(Note: s: second; data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study has investigated the effect of wearing solid AFO on the paretic TA and MG muscle contraction patterns during different gait phases in sub-acute stroke participants, by utilizing an innovative wearable ultrasound imaging and sensing system to thoroughly examine the internal activity and morphology of the TA and MG muscles in stroke survivors while walking with and without an AFO at the paretic side. The study results generally supported the hypothesis that solid AFO usage could positively affect the contraction patterns of paretic TA and MG muscles, as well as gait asymmetry and weight bearing, during walking in post-stroke patients. More detailed discussions can be found below.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTest-retest reliability\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe wearable ultrasound imaging and sensing system has demonstrated good to excellent test-retest reliability in capturing the thickness, sEMG signal, and sMMG signal of TA and MG muscles, as well as the plantar pressure, at the paretic side during walking in stroke survivors, both with and without AFO. These ICC values have been generally comparable to those reported for healthy people [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and stroke survivors [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMuscle thickness\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA consistently slight increase was observed in the paretic TA muscle thickness when AFO was used during walking in stroke participants. This increase may be contributed by the passively dorsiflexed ankle joint that maintained by the solid AFO in stroke participants, as compared to the original foot drop position (or plantarflexed ankle joint) while they were walking without AFO. Correspondingly and conversely, this study did observe a significant reduction in the MG muscle thickness while stroke participants were with AFO. This reduction could be due to the passive elongation of the MG muscle upon passively dorsiflexing the paretic ankle joint with an AFO, resulting in the decreased MG muscle thickness. Furthermore, the fluctuations in the MG muscle thickness throughout the gait cycle were more pronounced with the use of AFO compared to walking without AFO. The observed trend in muscle thickness variation with AFO application appears to align more closely with the patterns, particularly during the ISw and MSw phases, documented in healthy young adults by Ma et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], contrasting with the patterns observed during walking without AFO. These results indicate that the utilization of AFO may facilitate a more natural contraction of the paretic MG muscle during walking in stroke survivors. Further research could involve the development and application of wearable ultrasound imaging systems with enhanced imaging quality, capable of visualizing muscle fascicle length and pennation angle, to validate these observations.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMuscle electrical activity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study has observed the generally similar paretic TA sEMG trend during walking in stroke patients, regardless of with and without AFO, as that of a previous study reporting stroke survivors\u0026rsquo; muscle activity during natural walking [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The observed increased paretic TA sEMG signal when using AFOs may suggest that the AFO could facilitate the TA muscle contraction during the stance phase. This study has also observed that the use of AFO could significantly increase the TA muscle activity during ISw phase. This contradicted the previously reported finding of using AFO could decline TA muscle contraction during the swing phase, since the AFO could help maintain ankle joint in a neutral position, which may suppress the users from actively contracting the TA muscles by themselves [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This inconsistency may be attributed to the walking training that the participants underwent with the AFO prior to the walking trials in this study, in which all stroke participants were guided to engage the TA and MG muscles while walking with AFO by an experienced physiotherapist. This suggests that appropriate walking training with AFO in stroke patients may help to stimulate TA muscle activity during walking. This finding warrants further investigation in the long term.\u003c/p\u003e \u003cp\u003eAligning with the decreased thickness of the MG muscle, this study also observed significant reductions in MG sEMG signals during Isw and MSw phases while stroke participants walking with AFO compared to without AFO. This study also observed that MG muscle thickness significantly decreased during the MSw phase, while MG sEMG signals significantly decreased during Isw and MSw phases. This may be explained by delays in MG muscle activity where the timing of muscle sEMG signal generation was commonly earlier than that of muscle internal morphological contraction [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. It is also noteworthy to observe that significant differences in MG thickness were observed between two conditions of with and without AFO during MSt and TSt phases when analyzing ultrasound images. However, no significant difference was found in the MG sEMG signal during these two phases. Similarly, Choo et al. has utilized ultrasound imaging to detect the oropharyngeal swallowing events, and demonstrated its ability to further accurately capture the tongue base retraction and hyolaryngeal excursion during swallowing in young adults, which could not be detected using the sEMG electrodes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These results imply that ultrasound imaging could perform more effectively when capturing the internal morphological changes in muscles during dynamic activities; while the sEMG has been limited to detecting the muscle electrical activity from the skin surface, which may introduce more noise and crosstalk among neighboring muscles. This underscores the potential benefits of integrating both ultrasound imaging and sEMG measurements in future studies to gain a more comprehensive understanding of the lower-limb muscle activity across different dynamic conditions in participants.\u003c/p\u003e \u003cp\u003eThe significantly smaller CI values observed in the paretic TA and MG muscles during Isw and MSw phases suggest an improved co-contraction pattern between these two antagonist and agonist ankle muscles. This improved co-contraction may facilitate better ankle control and reduced energy expenditure during the ISw and MSw phases in the sub-acute stroke patients walking with AFO compared to walking without AFO [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The reduced CI values may be contributed by the more natural contraction of the paretic MG muscle during these two phases when using the AFO, as supported by the documented thickness of the paretic MG muscle documented in this study. Additionally, the overall reduced variability in CI values (i.e., reduced from 50\u0026ndash;22%) observed throughout a gait cycle may indicate a more stable co-contraction of the TA and MG muscles when using AFO. This increased stability in co-contraction may also contribute to a reduction in energy consumption during walking. Nevertheless, further research is needed to confirm these intriguing findings.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePlantar force and gait cycle\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eBy controlling the abnormal foot drop and plantar flexion using an AFO at the paretic side, the weight-bearing capacity of the paretic side during stance phase has significantly increased in stroke participants in this study. Additionally, it has also allowed the paretic ankle joint to adapt and accept loading more quickly during the loading response phase, and thereby reducing the time spent in the stance phase in stroke participants. Consequently, the proportions of the stance and swing phases in the gait cycle has improved, leading to a more symmetrical gait pattern and increased walking speed in stroke survivors using AFO. Such findings of this study have also been in accordance with the findings reported in previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSeveral limitations should be acknowledged when interpreting the findings of this pilot study. The lack of the comparison between the paretic and nonparetic sides made it difficult to determine how the use of AFO at the paretic side affected the performance of the nonparetic side during walking in stroke survivors. Given the impaired function at the paretic side, the nonparetic side may have some compensations during walking as reported in previous studies [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Furthermore, it is important to note that only the immediate impact of AFO use on the thickness and activity of the TA and MG muscles was examined in this pilot study, future studies shall also look into the long-term effects.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe results of this pilot study generally supported that the use of AFO could positively affect the contraction patterns of the paretic TA and MG muscles, as well as weight-bearing capacity and gait symmetry, during walking in the sub-acute stroke patients. However, future research is still needed to understand the long-term effects of AFO use in stroke patients.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eW.L. and H.-D.W. contributed to the conception, study design, data acquisition, analysis and interpretation, and draft of the manuscript. Y.-Y.L. contributed to the data acquisition, software development, data analysis and interpretation, and editing of the manuscript. R.T-L.Z. and Y.-Y.L. contributed to data analysis and editing of the manuscript. Y.T.L., L.-K.W., and J.-F.W. contributed to the hardware development, software development, and editing of the manuscript. Y-P.Z. contributed to the hardware and software development and editing of the manuscript. C.Z-H.M. contributed to conception, study design, funding acquisition, data analysis and interpretation, project supervision, and editing of the manuscript. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eData will be made available upon reasonable request from the corresponding author ([email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Ref:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eChiCTR2300074539; registration date: 09/08/2023; URL: https://www.chictr.org.cn/showproj.html?proj=203348\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Kunming Medical University Medical Ethics Committee (Ref: KMMU2023MEC149; date of approval: 23 May 2023). Informed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding resources:\u0026nbsp;\u003c/strong\u003eThis research was partially supported by the Research Institute for Smart Ageing (RISA), The Hong Kong Polytechnic University (Ref: P0038945); Department of Biomedical Engineering, The Hong Kong Polytechnic University (Ref: 9BH7).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLaufer, Y.;Hausdorff, J. M. \u0026amp; Ring, H. Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity. Am. J. Phys. Med. Rehab. 88, 14\u0026ndash;20 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitus, A. W.;Hillier, S.;Louw, Q. A. \u0026amp; Inglis-Jassiem, G. An analysis of trunk kinematics and gait parameters in people with stroke. Afr. J. Disabil. 7, 310 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKunkel, D.;Fitton, C.;Burnett, M. \u0026amp; Ashburn, A. Physical inactivity post-stroke: a 3-year longitudinal study. Disabil. Rehabil. 37, 304\u0026ndash;310 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawan, M. M.;Lawal, I. U. \u0026amp; Yusuf, A. M. Correlates of participation restrictions and quality of life among Hausa women with post-stroke disabilities. Bull. Fac. Phys. Ther. 27, 48 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham, J. Foot drop: explaining the causes, characteristics and treatment. Br. J. Neurosci. Nurs. 6, 168\u0026ndash;172 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang, G. E.;Frederick, R.;Nunley, B.;Lavery, L.;Dhaher, Y.;Najafi, B. \u0026amp; Cogan, S. The Effect of Implanted Functional Electrical Stimulation on Gait Performance in Stroke Survivors: A Systematic Review. Sensors 21, 8323 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMijic, M.;Schoser, B. \u0026amp; Young, P. Efficacy of functional electrical stimulation in rehabilitating patients with foot drop symptoms after stroke and its correlation with somatosensory evoked potentials\u0026mdash;a crossover randomised controlled trial. Neurol. Sci. 44, 1301\u0026ndash;1310 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaryabor, A.;Arazpour, M. \u0026amp; Aminian, G. Effect of different designs of ankle-foot orthoses on gait in patients with stroke: A systematic review. Gait Posture 62, 268\u0026ndash;279 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEveraert, D. G.;Stein, R. B.;Abrams, G. M.;Dromerick, A. W.;Francisco, G. E.;Hafner, B. J.;Huskey, T. N.;Munin, M. C.;Nolan, K. J. \u0026amp; Kufta, C. V. Effect of a Foot-Drop Stimulator and Ankle\u0026ndash;Foot Orthosis on Walking Performance After Stroke. Neurorehab. Neural. Re. 27, 579\u0026ndash;591 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto, M.;Shimatani, K.;Hasegawa, M.;Murata, T. \u0026amp; Kurita, Y. Effects of altering plantar flexion resistance of an ankle-foot orthosis on muscle force and kinematics during gait training. J. Electromyogr. Kines. 46, 63\u0026ndash;69 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurayama, M. \u0026amp; Yamamoto, S. Gait and Muscle Activity Changes in Patients in the Recovery Phase of Stroke with Continuous Use of Ankle\u0026ndash;Foot Orthosis with Plantarflexion Resistance. Prog. Rehabil. Med. 5, 20200021 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHesse, S.;Werner, C.;Matthias, K.;Stephen, K. \u0026amp; Berteanu, M. Non-velocity-related effects of a rigid double-stopped ankle\u0026ndash;foot orthosis on gait and lower limb muscle activity of hemiparetic subjects with an equinovarus deformity. 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Topics in Stroke Rehabilitation 25, 20\u0026ndash;27 (2018).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stroke, ankle-foot orthosis, gastrocnemius muscle, tibialis anterior muscle, contraction, walking","lastPublishedDoi":"10.21203/rs.3.rs-4217969/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4217969/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAnkle-foot orthosis (AFO) is commonly prescribed for stroke survivors with foot drop to aid in foot clearance while walking and reduce fall risk. However, its impact on the contraction patterns of paretic ankle muscles remains inconclusive. This pilot study investigated the contraction of paretic tibialis anterior (TA) and medial gastrocnemius (MG) muscles in twenty sub-acute stroke patients wearing AFO during walking using a wearable dynamic ultrasound imaging and motion sensors. Results showed an increase in TA muscle thickness throughout a gait cycle (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05) and a significant increase in TA muscle surface mechanomyography (sMMG) signal during pre- and initial swing phases (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) when using AFO. MG muscle thickness generally decreased with AFO (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05), aligning more closely with healthy adults' trends throughout a gait cycle. MG sEMG signal significantly decreased during the initial and mid-swing phases when wearing AFO (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). The TA-MG co-contraction index notably decreased during initial and mid-swing phases with AFO (\u003cem\u003ep \u003c/em\u003e\u0026lt; 0.05). These findings suggest that AFO can promptly influence the contraction patterns of paretic ankle muscles during walking in stroke patients, but further research is needed to understand its long-term effects.\u003c/p\u003e","manuscriptTitle":"Effect of ankle-foot orthosis on paretic gastrocnemius and tibialis anterior muscles contraction of stroke survivors during walking: a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 20:41:58","doi":"10.21203/rs.3.rs-4217969/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc35994a-5272-4232-899e-535b97f75d98","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31298194,"name":"Health sciences/Diseases/Cardiovascular diseases/Vascular diseases/Cerebrovascular disorders/Stroke"},{"id":31298195,"name":"Health sciences/Anatomy/Musculoskeletal system"},{"id":31298196,"name":"Health sciences/Health care/Medical imaging/Ultrasonography"}],"tags":[],"updatedAt":"2024-09-16T22:15:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-02 20:41:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4217969","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4217969","identity":"rs-4217969","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}