Neurol Sci
DOI 10.1007/s10072-017-3065-8
ORIGINAL ARTICLE
The effect of different ankle and knee supports on balance
in early ambulation of post-stroke hemiplegic patients
Burcu Talu 1 & Zilan Bazancir 1
Received: 30 May 2017 / Accepted: 10 July 2017
# Springer-Verlag Italia S.r.l. 2017
Abstract The purpose of this study was to compare the effects
of different ankle and knee supports on balance in early ambu-
lation of post-stroke hemiplegic patients. This is a randomized
experimental study. The study sample included 20 hemiplegic
patients who were able to stand with support and who had been
diagnosed with a cerebrovascular accident within the last
month. A knee immobilization brace (KIB) was first placed
on each individual (first application), followed by placement
of knee immobilizer brace and Foot Lifter Orthosis (FLO)
(second application), and lastly, placement of KIB and rigid
taping (RT) (third application). The balance parameters of the
patients were evaluated using the Korebalance system. The
mean age of the patients was 65.1 4.7 years, and the mean
number of days that had passed since stroke occurred was
14.6 4.97. In calculating the front/left balance scores of the
applications, statistically significant differences were observed
in the comparisons of all three supports and firstsecond appli-
cations performed (p = 0.041 and p = 0.021, respectively).
Regarding the total scores between the applications, statistically
significant differences were determined in balance in the com-
parisons on all three supports, in comparisons between the first
and second applications, and in the comparisons between the
second and third applications (p = 0.004, p = 0.007, and
p = 0.001, respectively). Based on the findings from this study,
it is recommended that the use of a knee immobilizer brace in
combination with a foot lifter orthosis for post-stroke
* Burcu Talu
fzt.burcu@hotmail.com
Zilan Bazancir
zilanbazancir@hotmail.com
1
Faculty of Health Sciences, Physiotherapy and Rehabilitation
Department, Inonu University, Malatya, Turkey
hemiplegic patients in early ambulation can lead to consider-
ably improved standing balance.
Keywords Balance . Foot lifter orthosis . Hemiplegia . Knee
immobilizer brace . Rigid taping
Introduction
Stroke is a major cause of mortality and disability worldwide
[1, 2]. Stroke-related hemiplegia may lead to decreased mo-
bility, altered gait pattern, impaired balance, postural instabil-
ity, limitations in daily life activities, and long-term disability
[35]. Following a stroke, persons with hemiplegia may face
many difficulties in the early recovery period [6]. The prob-
lems in balance that emerge from hemiplegia generally results
in unsteadiness, dynamic instability, and asymmetry [7]. One
of the most important goals in rehabilitation following a stroke
is to regain functional ambulation and standing balance [8, 9].
In addition to the rehabilitation methods used in the treat-
ment, knee-ankle-foot orthoses (KAFO) are prescribed once
the patients general condition has stabilized and they are able
to stand or engage in walking training, particularly in cases
where the knee and ankle joints are not yet stable because of
severe paralysis [10, 11]. However, KAFOs function as a
mechanism for helping hemiplegic persons resume walking
capabilities is limited since it is heavy and restrictive, requires
construction time, and is costly. Instead of KAFO, clinicians
often prefer to use a knee immobilizer brace (KIB), a type of
KAFO without the foot mechanism, which allows adjustment
of the position of the knee. KIBs have been shown to provide
knee stability in early stroke rehabilitation [12]. Furthermore,
the KIB is able to be easily adjusted with Velcro straps and
comes in standard sizes, features that provide time, and cost
advantages in the first ambulation.

Anklefoot orthoses (AFO) are commonly prescribed to
improve postural stability and functional mobility for per-
sons with hemiplegia [8, 13]. Many studies have been con-
ducted on the effect of AFO on balance, functional mobility,
hemiplegic gait, and energy expenditure, with most conclud-
ing that a suitable AFO could potentially improve balance
and function [14, 15]. Foot Lifter Orthosis (FLO), a type
of AFO with newly developed fabric for greater comfort,
has been shown to effectively provide mediolateral stability
and dorsiflexion [16]. Its use has been suggested for persons
with hemiplegia to control excessive foot inversion and
plantar flexion. Since the Foot Lifter can be adjusted with
velcroar until a customized AFO is made for the patient,
early rehabilitation can provide time and cost advantages
for initial ambulance.
Rigid taping (RT) techniques enable increased motor func-
tion and stability in the joints. This study has proven that
taping is able to effectively improve joint stability by biome-
chanically creating realignment of joints [17, 18]. The tape is
attached parallel or vertically to the joint to limit pathological
movement. Another method of taping is the McConnell taping
technique, which helps to maintain increased dynamic stabil-
ity during active exercise [19]. Taping is also effective for
improving balance and gait in stroke persons [20].
KIB, FLO, and RT are the most preferred methods in
clinics for the mobilization of hemiplegic persons. In ad-
dition to providing time and cost advantages, these sup-
ports also give joint stabilization for the mobilization of
hemiplegic persons in the early period. There is, however,
only a limited amount of data related to the efficacy of
different ankle and knee supports for early ambulation
balance in hemiplegic persons. The purpose of this study,
therefore, was to objectively evaluate the effect of differ-
ent ankle and knee supports on static balance in the early
ambulation of persons with hemiplegia.
Methods
All participants provided their informed consent before the
study was initiated. The experimental protocol was approved
based on the ethical standards of the Declaration of Helsinki.
The permissions and consents that were required for the study
were obtained from the Malatya Clinical Research Ethics
Committee (Approval number = 2016/76, Approval date =
06/04/2016).
In the power analysis performed with the NCSS PASS 13
program, the sample size was determined to have a 5% error
level, and at a 95% confidence interval, a sample size of at
least 16 had 80% power.
The target population of the study consisted of acute hemi-
plegic persons who had been diagnosed with a cerebrovascu-
lar accident between January 2016 and January 2017 at the
Neurol Sci
Turgut Ozal Medical Center Neurology Service of Inonu
University. Individuals that met the inclusion criteria
were selected out of the target population using proba-
ble simple random sampling. As part of the simple ran-
dom sampling method, individuals were listed by num-
ber, and those to be sampled were selected by using the
random number table.
A total of 20 ischemic persons with hemiplegia secondary
to stroke (10 female, 10 male, mean age 65.1 4.7) were
recruited for the study. To be included in the study, partici-
pants had to be between the ages of 55 and 76, have been
suffering from a stroke for a period of at least 1 month, have
the ability to stand with the support of a device, and have a
maximum spasticity score of 2 according to the Modified
Ashworth Scale. Individuals were excluded if they had lower
extremity deformities, orthostatic hypotension, or neurologi-
cal deficits (e.g., diplopia, ophthalmoplegia, and blurred vi-
sion.) or if they were capable of unsupported standing or ca-
pable of walking with support.
The demographic and clinical characteristics of the partic-
ipants (their age, sex, height, weight, body mass index, affect-
ed side, dominant side, number of days after stroke, presence
of aphasia and orthosis) were recorded. The Modified
Ashworth Scale (MAS) was used to determine upper and low-
er extremity spasticity. The MAS uses a five-point scale to
score the average resistance to passive movement for each
joint. A score of 0 on the MAS indicates no increase in muscle
tone, while a score of 4 indicates that the affected part is rigid.
MAS scores (0, 1, 1+, 2, 3, and 4) were assigned numerical
values, whereby for example, a score of 1 + was assigned the
value of 1.5 [21]. Babinski and clonus were evaluated as
pathological reflexes. The Visual Analogue Scale (VAS)
was used to evaluate the hemiplegic upper and lower
extremity pain associated with spasticity. A score of 0
on the VAS is defined as no pain and a score of 100 as
severe pain [22]. The Rivermead Mobility Index (RMI)
[23] was used to evaluate mobility. The RMI is scored
between 0 and 15 points, and 15 points indicate no mo-
bility problems while 14 points and below indicate dif-
ferent degrees of mobility difficulties. RMI has a simple
hierarchical structure, where degree of mobility problems
increases as the score decreases.
The Balance System SD (Korebalance Premier-19 Systems
Inc. USA) was used to measure static standing balance ability
by assessing posture imbalance, which was recorded as the
anterior-to-posterior postural sway and the medial-to-lateral
sway for 30 s. The Balance System SD facilitates the perfor-
mance of a 4-way evaluation of the balance of front/left, front/
right, behind/left, and behind/right and calculates total score.
The total score, including deviations caused by impairment of
postural balance, is calculated by the device. An increase in
the total score indicates worse balance; that is, higher total
scores indicate poorer balance and lower total scores, better
Neurol Sci
balance [24]. When the static balance parameters of the hemi-
plegic participants were evaluated, the ground instability in-
dex was set to 5, with the participants eyes open and their
hands on the device.
Three different ankle and knee supports were used to assess
balance in the early ambulance of the participants (Fig. 1).
KIB was applied in the first application; KIB and FLO were
applied in the second application; KIB and RT were applied in
the third application.
KIB was used to ensure knee stabilization and standing
balance. Two different sized KIBs were applied; one for male
hemiplegic persons and one for female hemiplegic persons.
The KIB was placed on the paralytic limb to control the pro-
gression of flexion and was reinforced in the posterior by
polyethylene to create a suitable position for the knee joint.
An anterior extension band was placed over the knee joint and
supported by two bands over the tibia and femur (Fig. 1a).
FLO (7210 Orthocare Foot Lifter) was used to control
abnormal plantar flexion and inversion of the ankle. This type
of brace was preferred for use on hemiplegic persons due to its
easy use in early rehabilitation, adaptability to every patient,
light weight, and ergonomic design. Three different body
types of FLO, a fabric orthosis, were used. The FLO brace,
which includes two bases and one accessory, was properly
fitted onto each of the participants (Fig. 1b).
RT was applied with a non-elastic band and medical tape to
control abnormal plantar flexion and inversion of the ankle.
For plantar flexion control, the ankle was placed in
dorsiflexion, and the first band was glued to the anterior mid-
point of the tibia on the dorsum of the foot. A second band was
attached to the tibia and fibula starting from the midpoint of
the medial and lateral metatarsal bones and crossing over the
anterior ankle. A third band was wrapped horizontally over
the talus to increase stability and prevent anterior tilt of the
Fig. 1 a Knee immobilizer brace. b Foot lifter orthosis. c Rigid taping
talus. Before performing the non-elastic tape application,
medical tape was applied (Fig. 1c).
Data analyses
The study data were analyzed using SPSS for Windows
(Version 16). The mean standard deviation value for the
variables that were determined by the measurement was also
calculated on this program. Since the data did not have a
normal distribution, the analyses were conducted using non-
parametric tests. Intergroup comparisons were made using the
Kruskal Wallis test. Post hoc analysis was performed to deter-
mine the group that generated any significant differences.
When the significance of the difference between two means
was determined, the Mann-Whitney U test was used for the
data that did not meet the parametric conditions. The signifi-
cance level was p < 0.05 in the analyses.
Results
A total of 20 ischemic hemiplegic persons (10 males and 10
females) participated in this study. The mean age of the par-
ticipants was 65.1 4.7 years (range 5876 years), and their
mean RMI score was 4.05 0.5. Demographic and clinical
characteristics of the participants are shown in Table 1 as
means and standard deviations. Table 2 presents more detailed
characteristics of the participants. In calculating the front/left
balance scores of the applications, statistically significant dif-
ferences emerged in the comparisons of all three supports
regarding balance, as well as in the comparisons of the first
and second applications (p = 0.041 and p = 0.021, respective-
ly). Regarding the total scores between the applications, sta-
tistically significant differences were observed in the
 Neurol Sci

Table 1 Demographic and clinical characteristics of the patients Discussion

(n = 20) Mean SD Min Max
This study investigated the effect on balance of different knee
Age 65.1 4.7 58 76 and ankle supports in early ambulation of hemiplegic persons.
Height (cm) 167 9.7 155 182 It was found that FLO was more effective than RT, and that in
Weight (kg) 83.05 8.7 65 100 terms of providing static balance, KIB combined with FLO
BMI (kg/m2) 29.8 3.2 24 39 was more effective than KIB combined with RT. This is the
Time after stroke (day) 14.6 4.97 8 28 first study to compare the effect on balance of different sup-
RMI score 4.05 0.5 3 5 ports used in early ambulation in the rehabilitation of hemi-
VAS for upper extremity 3.45 1.7 0 6 plegic persons.
VAS for lower extremity 1.75 1.2 0 4 A study by Whang et al. demonstrated that the use of AFO
MAS for upper extremity 0.77 0.6 0 2 improved body symmetry and dynamic standing balance in
MAS for lower extremity 1.35 0.3 1 2 early period hemiplegic persons yet it had minimal long-term
effects [25]. In another study, the use of AFO was shown to
BMI body mass index, RMI Rivermead mobility index, VAS Visual significantly improve walking speed, step length, and cadence
Analogue Scale, MAS Modified Ashworth Scale, SD Standard deviation
in hemiplegic persons after an average of 1 month according
to spatiotemporal and three-dimensional gait analyses [26]. A
study that was conducted with hemiplegic persons by Simons
Table 2 Frequency distributions of patient characteristics
et al. reported that AFOs resulted in improvements on the
n = 20 N Percent Berg Balance Scale, timed up and go, functional ambulatory
category, and walking speed [15]. In this study, the use of KIB
Gender Male 10 50 with FLO was more effective than the use of KIB alone in the
Female 10 50 development of static balance. Given the poor ankle stability
Affected side Right 9 45 of hemiplegic persons, the use of KIB alone in their early
Left 11 55 ambulance is not sufficient for providing static balance.
Aphasia No 14 70 Rather, static balance can be provided more effectively by
Broca 5 25 the combination of FLO application to the ankle and KIB.
Wernicke 1 5 In a study conducted by Maguire et al., hip abductor taping
Right dominant 20 100 in hemiplegic persons was found to increase hemiplegic hip
7 35 abductor activity and gait speed. Taping has been shown to be
Patients with clonus 20 100 effective in increasing balance reactions and muscle activity
Patients with babinski
Sensation of underfoot 10 50 [27]. A study on hemiplegic individuals conducted by Hyun
Sensation of passive motion 12 60
et al. indicated that the application of taping effectively im-
proved the balance and gait of these individuals [20]. In an-
other study, tape applied on the gluteus medius, gluteus
comparisons regarding balance on all three supports in the maximus, tibialis anterior, and transversus abdominis muscles
comparisons between the first and second applications, and of the paralytic side of hemiplegic persons resulted in a sig-
in the comparisons between the second and third applications nificant change in the parameters related to balance (BBS,
(p = 0.004, p = 0.007, and p = 0.001, respectively) (Table 3). standing on the leg of the paretic side, standing on the leg of

Table 3 Comparison among applications in terms of balance

n = 20 1st application (Only KIB) 2nd application (KIB and FLO) 3rd application (KIB and RT) Between applications
X SD X SD X SD
3a 12 13 23

Front/left 119.05 263.56 34.95 137.73 85.50 222.05 0.041* 0.021* 0.277 0.369
Front/right 148.30 223.30 91.45 205.04 115.65 218.48 0.345 0.183 0.383 0.799
Behind/left 218.70 264.59 202.45 244.88 202.45 296.30 0.507 0.620 0.253 0.583
Behind/right 176.05 248.22 160.15 202.54 280.80 317.39 0.611 0.779 0.383 0.478
Total score 662.6 206.26 489.45 179.19 684.65 195.37 0.004* 0.007* 0.841 0.001*

*p < 0.05
a
Kruskal Wallis, Mann Whitney U test
Neurol Sci
the non-paretic side, 360 rotation on the paretic side, 360
rotation on the non-paretic side, raising the legs alternatively)
[28]. This study found that KIB combined with RT positively
influenced the balance, but when comparing the use of only
KIB and KIB combined with RT, neither was superior to the
other in providing static balance in hemiplegic persons. RT
may not provide adequate stabilization because in the early
period, hemiplegic persons have poor foot and ankle stability.
In this respect, neither KIB nor KIB with RT has an advantage
over one another. Considering this finding, RT may be inade-
quate for providing balance via stabilization of the ankle in the
early period.
A relevant study proved that KIB improved the daily life
capacity and reduces the time of hospital stay in severe hemi-
plegic persons during the hospitalization period. It has been
reported that KIB and AFO tend to be used together early in
hemiplegic persons with severe paralysis, and that most per-
sons withdraw from the use of KIB after undergoing rehabil-
itation [29]. This study determined that there was a difference
between FLO and RT when applied respectively with KIB,
which was used to secure the knee in early ambulation and
to protect static balance, and that this difference was found to
originate from FLO. Moreover, KIB combined with FLO was
more effective than KIB combined with RT in providing
standing balance for hemiplegic persons in the early period.
FLO is superior to RT because it is more effective in providing
foot and ankle stabilization.
One important limitation of this study is that the dynamic
balance could not be assessed. This was due to the insufficient
proximal and distal muscle strength and trunk control of the
early hemiplegic persons and to the fact that the persons were
evaluated by providing them only distal stabilization with the
applied supports. A study related to this topic involved this
same limitation. In a study on neuromuscular diseases, per-
sons were divided into two groups, one group with proximal
muscle weakness and the other group with distal muscle
weakness. Afterwards, four-way balance parameters were
tested with stabilometric platform, and the results of this op-
eration showed that proximal muscle weakness was correlated
with static balance and distal muscle weakness with dynamic
balance [30]. Furthermore, it was not possible in this study to
assess the balance of these supports in isolation due to the
impossibility of maintaining standing balance with FLO or
RT alone in the early ambulation.
Conclusion
FLO and KIB can be used to effectively provide static balance
in the early ambulation of persons who have had an ischemic
hemiplegic stroke. For early mobilization of post-stroke per-
sons, the combination of a knee immobilizer brace and a foot
lifter orthosis is recommended for early rehabilitation. In early
rehabilitation units, KIB combined with FLO can be applied
to achieve success in the early mobilization of the persons and
has the added benefit of reducing health costs.
Acknowledgements We would like to thank the neurologist Suat
Kaml, who helped us access the persons included in the study during
the collection of the data.
Compliance with ethical standards
Funding The authors received no financial support for the research,
authorship and/or publication of this article.
Conflict of interest The authors declare that they have no conflict of
interest.
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