Identification of stiff-knee gait in stroke survivors

doi:10.21203/rs.3.rs-4797428/v1

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Identification of stiff-knee gait in stroke survivors

https://doi.org/10.21203/rs.3.rs-4797428/v1

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published 01 Sep, 2025

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Background: Though stiff-knee gait is a common movement disorder in individuals with stroke, the criteria for identifying it in this population are not yet well established. This study investigated suitable criteria to identify stroke survivors with stiff-knee gait. Twenty-four stroke survivors (45.2±13.7 years old) and 24 individuals matched by age and sex (45.5±13.5 years old) with no known gait impairment participated in this study. They walked along a 10-m extension walkway at a self-selected comfortable speed. A computerized analysis system registered the trajectories of retroreflective markers placed on specific body landmarks, and different measurements were calculated regarding knee flexion during gait cycle, such as its peak during the swing period, total range of motion (RoM), equivalent to the difference between maximum and minimum knee excursion during gait cycle (“RoM cycle”), and RoM from toe-off to peak knee flexion (“RoM swing”).

Results: Overall, peak knee flexion during the swing period and knee RoM swing were the most remarkable measurements to identify stiff-knee gait in stroke survivors.

Conclusions:Based upon the found results, we suggest using at least two criteria to identify stiff-knee gait in individuals with stroke. The most suitable ones are peak knee flexion during the swing period <50° and the knee RoM from toe-off to peak knee flexion <12°. Finally, our results suggest that it is inappropriate to consider the non-paretic limb and total knee flexion RoM to classify stiff-knee gait in individuals with stroke.

kinematics

walking

range of motion

peak knee flexion

Limited knee flexion during the swing period of the gait is a common movement disorder in stroke survivors [1, 2, 3], often referred to as a stiff-knee gait [4]. Consequences of a stiff knee gait include reduced foot clearance leading to tripping, increased risk of falling, compensatory movements, and increased energy expenditure [5]. Although several studies have explored the causes of stiff knee gait in stroke survivors [6, 7] and appropriate treatments to diminish its consequences [8, 9, 10], the standardized criteria for identifying individuals with stiff knee gait who have also experienced stroke are not well established. A recent attempt to classify the severity of stiff knee gait in stroke survivors using retrospective unsupervised cluster analysis [11] has highlighted the need for standardization to characterize this movement disorder in patients with a stroke.

Different criteria have been employed to identify stiff knee gait in stroke survivors. The most commonly used applied quantitative criteria are peak knee flexion of less than 45° during the swing period [6, 12], range of motion from toe-off to maximum knee flexion of less than 10° in the swing period [2], range of motion of at least 16° [13] or 20° [7] less on the paretic limb compared to the non-paretic limb. In addition, the same criteria have been applied as in children with cerebral palsy [8]. A subjective criterion “observable reduced maximum knee flexion during the swing period” [10, 14, 15] has been employed to identify the stiff-knee gait in these individuals.

Stiff-knee gait is common among stroke survivors, prompting many investigations into mitigating its impact on daily life activities. Standardizing the characterization of stiff-knee gait specifically for these individuals seems appropriate. In children with cerebral palsy, whose stiff knee gait is also a common gait disturbance [16], other criteria have been used to identify those with a stiff knee gait, such as maximum knee flexion in the swing period, range of knee motion, and timing of maximum knee flexion during the swing period [16, 17, 18, 19, 20]. Goldberg et al. [18] selected four gait parameters to identify stiff knee gait in children with cerebral palsy: (1) maximum knee flexion in the swing period, (2) knee range of motion from toe-off to maximum knee flexion in the swing period, (3) total knee range of motion during the gait cycle, and (4) timing of maximum knee flexion during the swing period of gait.

The general characteristics of patients with cerebral palsy differ from those of stroke survivors in many aspects. For example, individuals with cerebral palsy commonly present with secondary deficits, such as muscle contractures and bone deformities [21]. Furthermore, gait deviation in these individuals may vary depending on the topography of the impairment [22], such as spastic hemiplegia (drop foot, equinus gait with different knee positions), spastic diplegia (jump knee gait, crouch gait) [23], and other motor disturbances [24]. In contrast, stroke survivors and individuals with cerebral palsy commonly experience adverse effects, such as spasticity, muscle weakness, and loss of selective motor control [25, 26]. Nevertheless, considering the four gait parameters identified by Goldberg et al. [18] as a basis for standardizing the characterization of stiff knee gait in stroke survivors is plausible.

The study aimed to examine suitable criteria for identifying stroke survivors with a stiff knee gait by assessing the strengths and limitations of the criteria adopted by Goldberg et al. [18] for stroke survivors who present with stiff knee gait.

Participants

Twenty-four stroke survivors and 24 individuals matched by age and sex (control group), were conveniently sampled and included in this cross-sectional study. The inclusion criteria for stroke survivors having experienced stroke (either ischemic or hemorrhagic) more than 6 months prior, ability to walk at least 10 m with no assistance, ability to follow verbal instruction, absence of any orthopedic or neurological impairment other than stroke, and no surgical intervention, including botulinum toxin injection, within the previous 6 months. For the control group, the inclusion criterion was the absence of any known neurological or orthopedic impairment or musculoskeletal injury that could compromise gait. The Institutional Review Board of Cruzeiro do Sul University approved all procedures. All participants provided written informed consent prior to the experimental session.

Procedures

Following the recommendations of the International Society of Biomechanics (ISB) [27], retroreflective markers and rigid clusters were placed on specific body anatomical landmarks and lower limb segments, as described in previous studies [28, 29]. A calibrated anatomical system technique (CAST) was employed to record the three-dimensional kinematics of the lower extremities [30].

A t-pose kinematic calibration trial was performed with all retroreflective markers placed on anatomical landmarks. Subsequently, markers from the anterior and posterior superior iliac spine, medial and lateral epicondyles of the femur, tibialis tuberosity, medial and lateral malleoli, and intermalleolus were removed.

Each participant walked in their own shoes at a self-selected comfortable speed on a 10-m extension walkway equipped with two embedded force plates (Kistler, model 9286BA) covered with a thin rubber carpet. Prior to data acquisition, the participants practiced a few trials until they felt comfortable with the experimental setup. Each participant underwent a minimum of five trials. A computerized gait analysis system (VICON, Inc.) with eight infrared cameras was used to synchronously acquire all the marker positions and force plate data at a frequency of 100 Hz.

Stroke survivors were clinically examined using the Fugl-Meyer test [31] and functional independent measurements (motor domain) [32]. These data were solely used for characterizing these individuals.

Data processing and analysis

We analyzed two consecutive steady-state strides (paretic and non-paretic for stroke survivors, and right and left for the control group) per trial, for a total of five trials for each participant. Foot contact and toe-off events were identified for each stride using force plate signals and foot vertical velocity [33]. These events were used to define each stride and calculate the stance and swing periods [4].

The knee joint angle was calculated using a commercial algorithm (Visual3D; C-Motion, Inc.) and further analyzed using custom algorithms (MATLAB; MathWorks, Inc.). Kinematic data were digitally filtered using a low-pass 4th order, and zero-lag Butterworth filter with a 6 Hz cut-off. The gait cycle durations were time-normalized and averaged to obtain the mean cycle for each participant.

We quantified four parameters: (1) peak knee flexion during the swing period of gait, identifying the maximum value of knee flexion, (2) knee range of motion (RoM) from toe-off to peak flexion, calculated as the difference between maximum knee angle and knee angle at toe-off (RoM-swing), (3) total knee RoM across the entire gait cycle, calculated as the difference between maximum and minimum knee angles, and (4) timing to peak knee flexion during the swing period of gait, expressed as a percentage of the stance period duration, as in previous investigation [18]. Figure 1 illustrates each of these four parameters. Subsequently, we replicated the procedures adopted by Goldberg et al. [18] to calculate the average value of each parameter for the control group (“normal values”) and used the values to identify the “stiff-knee,” as the stroke survivors presented the values greater than two standard deviations either below (for parameters 1–3) or above (for the parameter 4) the observed average normal value. A limb was classified as “stiff-knee” if at least three of these four parameters met the established criteria [18].

[Figure 1 near here]

The following variables were selected for analysis: mean walking speed; instant of occurrence of toe-off and peak knee flexion during swing period; peak knee flexion during the swing period; RoM of knee flexion from toe-off to peak knee flexion (“RoM swing”); total RoM of knee flexion (“RoM cycle”); and timing to maximum knee flexion during the swing period.

Notably, no limb effects were observed in the control group; we combined data from the right and left limbs and considered them as the “control limb”[28].

Statistical analyses

One-way univariate analyses of variance (ANOVA) were employed to compare age and mean walking speed between both groups (stroke and control), as well as to compare swing duration and timing to peak knee flexion among limbs (control, paretic, and non-paretic). One-way multivariate analysis of variance (MANOVA) was used to compare body mass and height between the groups, with the limb (control, paretic, and non-paretic) as a factor for the following dependent variables: an instant of toe-off, instant of peak knee flexion, peak knee flexion, and knee RoM during swing.

Univariate analysis and post-hoc pairwise comparisons with Bonferroni adjustments were performed as necessary. An alpha of 0.05 was set for all statistical tests, which were performed using SPSS software.

Following the four stiff knee criteria [18] for the paretic limb, three stroke survivors did not meet at least three of these criteria and were excluded from the matched controls. Among the remaining stroke survivors (n = 21), some did not meet the criteria in the paretic limb for peak knee flexion during the swing period (n = 1), knee RoM swing (n = 2), knee RoM cycle (n = 1), or the timing of peak knee flexion (n = 20). For the nonparetic limb, some did not meet the criteria for peak knee flexion during the swing period (n = 4), knee RoM swing (n = 10), knee RoM cycle (n = 11), or timing of peak knee flexion (n = 20).

Table 1 presents the general characteristics of the 21 participants in each group (stroke and control) that were considered for further analysis. ANOVA revealed no group effect for age (F_1,41=0.004, p = 0.951), and MANOVA revealed no group effect for mass or height (Wilks’ Lambda = 0.87, F_2,39=2.83, p = 0.071). Stroke survivors were in the chronic stage, and most exhibited high levels of motor function (Table 1).

Table 1

General characteristics of participants analyzed
Characteristics	Stroke	Control
Sex (female/male)	14/7	14/7
Age (years)*	46.4±13.8	46.5±13.8
Mass (kg)*	77.0±20.4	67.6±10.3
Height (m)*	1.67±0.09	1.65±0.10
Time poststroke (months)*	84.6±40.5	-
Type of lesion (ischemic/hemorrhagic)	12/9	-
Hemiparesis side (right/left)	12/9	-
Fugl-Meyer score (maximum, 84)*	63.9±5.9	-
Functional independence (maximum, 91)*	81.7±4.1	-
* Mean±standard deviation

Regarding walking speed, ANOVA revealed that stroke survivors walked slower (0.64±0.28 m/s) than their peers (1.26±0.13 m/s) (F_1,41=90.36, p < 0.001). In addition, ANOVA results indicated a limb effect on swing period duration (F_2,62=379.88, p < 0.001). Post hoc tests showed shorter swing durations for the paretic and non-paretic limbs than for the control limb and longer swing durations for the paretic limb than for the non-paretic limb (Table 2).

Table 2

Mean (±SD) values of instants of toe-off and peak knee flexion during the swing period, swing duration, and timing of peak knee flexion for the control limb in the control group and for the paretic and non-paretic limbs in individuals with stroke.
Measures	Control	Paretic	Non-paretic
Swing duration (%)	39.8±1.4	35.4±6.6	27.7±6.7
Instant of toe-off (%)	60.2±1.43	64.6±6.6	72.3±6.7
Instant of peak knee flexion (%)	70.5±1.3	70.8±6.8	79.0±4.8
Timing of peak knee flexion (% swing period)	25.7±2.2	18.2±7.4	23.8±4.1

Regarding the timing of toe-off and peak knee flexion, MANOVA revealed a limb effect (Wilks’ Lambda = 0.34, F_4,118=21.29, p < 0.001). Univariate analysis revealed differences in toe-off (F_2,62=26.17, p < 0.001) and peak knee flexion (F_2,62=20.87, p < 0.001) between groups. Post hoc tests revealed that toe-off occurred later in the gait cycle for the non-paretic limb compared to the paretic and control limbs, and later in the paretic limb than in the control limb. Peak knee flexion occurred later in the non-paretic limb than in the paretic and control limbs (Table 2). ANOVA for the timing of peak knee flexion also revealed a limb effect (F_2,62=12.64, p < 0.001). Post-hoc tests showed that peak knee flexion occurred earlier for the paretic limb than for the non-paretic and control limbs (Table 2).

Figure 2 shows the mean (±SD) time series of the knee angles for the control, paretic, and non-paretic limbs during the gait cycle. Overall, the kinematic patterns were similar for the three limbs but still depicted some adaptations. For instance, knee flexion of the paretic limb was reduced compared to that of the control and non-paretic limbs, and peak knee flexion occurred later in the non-paretic limb compared to the control and paretic limbs.

[Figure 2 near here]

Figure 3 depicts the mean (±SD) values of peak knee flexion during the swing period, knee RoM swing, and knee RoM cycle in the control, paretic, and non-paretic limbs. MANOVA revealed a limb effect (Wilks’ Lambda = 0.21, F_6,116=22.84, p < 0.001). Univariate analyses revealed differences in the peak knee flexion (F_2,62=55.77, p < 0.001), knee RoM swing (F_2,62=37.09, p < 0.001), and knee RoM cycle (F_2,62=38.72, p < 0.001). Post hoc tests revealed reduced peak flexion, RoM swing, and RoM cycle for the paretic limb compared to the non-paretic and control limbs, and reduced RoM swing and RoM cycle for the non-paretic limb compared to the control limb.

[Figure 3 near here]

In this study, we examined the suitable criteria for identifying stiff knee gait in stroke survivors. Among the four criteria adopted by Goldberg et al. [18], peak knee flexion during the swing period was the most remarkable for these individuals, followed by the RoM of knee flexion from toe-off to peak flexion during swing. However, total knee flexion RoM and the timing of peak knee flexion were not suitable for identifying stiff knee gait in stroke survivors.

Regarding the total knee flexion RoM, it is important to note that the knee displacement observed in stroke survivors in this study was different from that in individuals with cerebral palsy. Specifically, while individuals with cerebral palsy usually adopt either a crouched or a jump gait during the stance period [34, 35], most of stroke survivors presented with knee hyperextension. These behavioral differences affect the total RoM knee flexion and could lead to a misleading criterion for identifying stiff knee gait in stroke survivors.

Regarding the timing of peak knee flexion during the swing period, stroke survivors anticipated maximum knee flexion compared to individuals with cerebral palsy [18], with high variability for the paretic limb (Table 2). Although there is a consensus that diminished peak knee flexion during the swing period of gait that characterizes stiff-knee gait in stroke survivors [2, 3, 6, 12, 18], it remains unclear whether it occur either earlier or later in the swing period of a gait cycle. Contrary to the knee angle, which indicates the relative excursion between the thigh and shank, the timing is directly related to the locomotor coordination, which is affected in stroke survivors [36, 37]. However, the relative timing of the stance and swing periods of the gait cycle differs between stroke survivors and non-disabled individuals [36], as well as between paretic and non-paretic limbs [36, 38]. Notably, locomotor coordination disturbances might be due to factors other than stiff-knee gait, such as slow walking speed and balance impairment. Therefore, we suggest that the timing of peak knee flexion is not a suitable criterion for identifying stiff knee gait in stroke survivors.

Altogether, the findings of this study suggest that the most suitable criteria for identifying stiff knee gait in individuals with stroke are maximum knee flexion < 50° and ROM of knee flexion from toe-off to peak flexion at swing < 12°. Nevertheless, if one decides to use the timing of peak knee flexion during the swing period as a criterion, the value to be considered should be < 21%. Finally, our results suggest that it is inappropriate to consider the non-paretic limb to identify stiff-knee gait in stroke survivors, as in previous investigations [7, 13]. Our results revealed that some of the criteria were also observed for the non-paretic limb in some stroke survivors, and differences were noted between the non-paretic and control limbs (Table 2, Fig. 2). This finding is probably due to motor compensation [39], which could lead to the appropriate identification of stiff-knee gait for these individuals.

Although the present study provides valuable insights into standardizing the criteria for identifying stiff knee gait in stroke survivors, several limitations should be noted. First, the sample size was limited to 24 stroke survivors with a high level of independence, predominantly under 55 years of age (n = 16), which could be explained by the increase in stroke incidence among younger individuals [40]. Second, this study was limited to investigating suitable criteria for identifying stiff knee gait in stroke survivors. Future studies should employ these criteria adopted in this study across a wider range of stroke survivors in terms of independence level and age and investigate the causes of their stiff-knee gait, which was beyond the scope of this study.

In summary, based on our findings, the suitable criteria for identifying stiff knee in stroke survivors are preferentially peak knee flexion during the swing period < 50° and knee RoM from toe-off to peak knee flexion < 12°.

CAST: calibrated anatomical system technique; RoM: range of motion; ANOVA: univariate analyses of variance; MANOVA: multivariate analyses of variance.

Ethics approval and consent to participate

The Institutional Review Board of Cruzeiro do Sul University approved all procedures. All participants provided written informed consent prior to the experimental session.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by the São Paulo Research Foundation (FAPESP) under the grant number 2018/04964-8.

Authors’ contribution

OB contributed to the acquisition, analysis, and interpretation of data, and have drafted the work; MLC and JAB contributed to the interpretation of data and substantively revised the work; AMFB contributed to the conception of the work, analysis and interpretation of data, and substantively revised it. All authors read and approved the submitted version.

Acknowledgments

Not applicable

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No competing interests reported.

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Identification of stiff-knee gait in stroke survivors

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Abstract

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Background

Methods

Participants

Procedures

Data processing and analysis

[Figure 1 near here]

Statistical analyses

Results

[Figure 2 near here]

[Figure 3 near here]

Discussion

Conclusion

Abbreviations

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References

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