Acu-TENS to Improve the Sleep Quality in People with Stroke

The subjective sleep quality will be assessed by the Pittsburgh sleep quality index. It has been used in both research and clinical settings to evaluate sleep quality and screen for sleep disturbances. The scores ranges from 0 to 21. A higher score means a lower sleep quality, with a score ≥ 6 as the cut-off value for poor sleep quality. The Chinese version will be used in the proposed study.

The subjective sleep quality will be assessed by the Pittsburgh sleep quality index. It has been used in both research and clinical settings to evaluate sleep quality and screen for sleep disturbances. The scores ranges from 0 to 21. A higher score means a lower sleep quality, with a score ≥ 6 as the cut-off value for poor sleep quality. The Chinese version will be used in the proposed study.

The subjective sleep quality will be assessed by the Pittsburgh sleep quality index. It has been used in both research and clinical settings to evaluate sleep quality and screen for sleep disturbances. The scores ranges from 0 to 21. A higher score means a lower sleep quality, with a score ≥ 6 as the cut-off value for poor sleep quality. The Chinese version will be used in the proposed study.

The subjective sleep quality will be assessed by the Pittsburgh sleep quality index. It has been used in both research and clinical settings to evaluate sleep quality and screen for sleep disturbances. The scores ranges from 0 to 21. A higher score means a lower sleep quality, with a score ≥ 6 as the cut-off value for poor sleep quality. The Chinese version will be used in the proposed study.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' total sleep time (total time asleep from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' total sleep time (total time asleep from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' total sleep time (total time asleep from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' sleep efficiency (percentage of total time in bed trying to sleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' sleep efficiency (percentage of total time in bed trying to sleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants' sleep efficiency (percentage of total time in bed trying to sleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'sleep onset latency (time to fall asleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'sleep onset latency (time to fall asleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'sleep onset latency (time to fall asleep). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'time awake after sleep onset (total time awake from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'time awake after sleep onset (total time awake from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

Actigraphy (Ambulatory Monitoring, Inc., Ardsley, NY, or equivalent device) will be used to measure participants'time awake after sleep onset (total time awake from sleep onset to waking). Actigraphy is a non-invasive technique that involves the use of a wearable device to objectively measure sleep in terms of ambulation. Thus, actigraphic sleep metrics are based on the principle that sleep is characterized by the relative absence of movement. Participants will be instructed to wear an actigraphy device on one of their legs and press the event-marker to record bedtimes and rise time for three consecutive days at each assessment point (i.e., T0, T2, T3). The validity of this assessment was confirmed in previous research.

The subjective perception of the severity of insomnia will be assessed by Insomnia severity index. It comprises seven items measuring the severity of sleep-onset and sleep maintenance difficulties (both nocturnal and early-morning awakenings), satisfaction with the current sleep pattern, the adverse effects of insomnia on daily functioning, noticeability of impairment attributed to the sleep problem, and degree of distress or concern caused by the sleep problem. Each item is rated on a scale from 0 to 4, and the total score ranges from 0 to 28. A higher score represents more severe insomnia. The Chinese version will be used in the proposed study.

The subjective perception of the severity of insomnia will be assessed by Insomnia severity index. It comprises seven items measuring the severity of sleep-onset and sleep maintenance difficulties (both nocturnal and early-morning awakenings), satisfaction with the current sleep pattern, the adverse effects of insomnia on daily functioning, noticeability of impairment attributed to the sleep problem, and degree of distress or concern caused by the sleep problem. Each item is rated on a scale from 0 to 4, and the total score ranges from 0 to 28. A higher score represents more severe insomnia. The Chinese version will be used in the proposed study.

The subjective perception of the severity of insomnia will be assessed by Insomnia severity index. It comprises seven items measuring the severity of sleep-onset and sleep maintenance difficulties (both nocturnal and early-morning awakenings), satisfaction with the current sleep pattern, the adverse effects of insomnia on daily functioning, noticeability of impairment attributed to the sleep problem, and degree of distress or concern caused by the sleep problem. Each item is rated on a scale from 0 to 4, and the total score ranges from 0 to 28. A higher score represents more severe insomnia. The Chinese version will be used in the proposed study.

The subjective perception of the severity of insomnia will be assessed by Insomnia severity index. It comprises seven items measuring the severity of sleep-onset and sleep maintenance difficulties (both nocturnal and early-morning awakenings), satisfaction with the current sleep pattern, the adverse effects of insomnia on daily functioning, noticeability of impairment attributed to the sleep problem, and degree of distress or concern caused by the sleep problem. Each item is rated on a scale from 0 to 4, and the total score ranges from 0 to 28. A higher score represents more severe insomnia. The Chinese version will be used in the proposed study.

The ability to inhibit cognitive interference will be measured by the Stroop Color and Word Test. The Stroop Test consists of 3 subtasks. The first subtask shows color dots (green, blue, yellow, red) in random order. The second subtask shows the words (green, blue, red, yellow) in random order. The third task showed color words (green, blue, red, yellow) printed in a different ink color (i.e., the word blue printed in yellow ink). Participants are required to name the color of the ink as quickly as possible within 45 s in each task. The completion time and number of error is recorded in each task. The interference ratio of will be calculated as the completion time of the third task/the completion time of the first task. A higher interference score indicated poorer interference control.

The ability to inhibit cognitive interference will be measured by the Stroop Color and Word Test. The Stroop Test consists of 3 subtasks. The first subtask shows color dots (green, blue, yellow, red) in random order. The second subtask shows the words (green, blue, red, yellow) in random order. The third task showed color words (green, blue, red, yellow) printed in a different ink color (i.e., the word blue printed in yellow ink). Participants are required to name the color of the ink as quickly as possible within 45 s in each task. The completion time and number of error is recorded in each task. The interference ratio of will be calculated as the completion time of the third task/the completion time of the first task. A higher interference score indicated poorer interference control.

The ability to inhibit cognitive interference will be measured by the Stroop Color and Word Test. The Stroop Test consists of 3 subtasks. The first subtask shows color dots (green, blue, yellow, red) in random order. The second subtask shows the words (green, blue, red, yellow) in random order. The third task showed color words (green, blue, red, yellow) printed in a different ink color (i.e., the word blue printed in yellow ink). Participants are required to name the color of the ink as quickly as possible within 45 s in each task. The completion time and number of error is recorded in each task. The interference ratio of will be calculated as the completion time of the third task/the completion time of the first task. A higher interference score indicated poorer interference control.

The ability to inhibit cognitive interference will be measured by the Stroop Color and Word Test. The Stroop Test consists of 3 subtasks. The first subtask shows color dots (green, blue, yellow, red) in random order. The second subtask shows the words (green, blue, red, yellow) in random order. The third task showed color words (green, blue, red, yellow) printed in a different ink color (i.e., the word blue printed in yellow ink). Participants are required to name the color of the ink as quickly as possible within 45 s in each task. The completion time and number of error is recorded in each task. The interference ratio of will be calculated as the completion time of the third task/the completion time of the first task. A higher interference score indicated poorer interference control.

The attention and cognitive flexibility will be assessed by trial making test. The test is divided into two parts: A and B. In part A, the circle is numbered (i.e., 1 to 25). The participants should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L); the participants should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). The test will be timed with a shorter time indicated the better performance. The test-retest reliability is good in stroke patients (ICC; 0.94 and 0.86 for Part A and Part B, respectively)

The attention and cognitive flexibility will be assessed by trial making test. The test is divided into two parts: A and B. In part A, the circle is numbered (i.e., 1 to 25). The participants should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L); the participants should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). The test will be timed with a shorter time indicated the better performance. The test-retest reliability is good in stroke patients (ICC; 0.94 and 0.86 for Part A and Part B, respectively)

The attention and cognitive flexibility will be assessed by trial making test. The test is divided into two parts: A and B. In part A, the circle is numbered (i.e., 1 to 25). The participants should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L); the participants should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). The test will be timed with a shorter time indicated the better performance. The test-retest reliability is good in stroke patients (ICC; 0.94 and 0.86 for Part A and Part B, respectively)

The attention and cognitive flexibility will be assessed by trial making test. The test is divided into two parts: A and B. In part A, the circle is numbered (i.e., 1 to 25). The participants should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L); the participants should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). The test will be timed with a shorter time indicated the better performance. The test-retest reliability is good in stroke patients (ICC; 0.94 and 0.86 for Part A and Part B, respectively)

The functional mobility will be assessed by the 10-m walk test. Participants will be instructed to walk without assistance for a 10-m distance in a solid flooring with a clear pathway. A mark at 2-m and 8-m will be placed. A stopwatch will be timed central 6-m to assess participants' acceleration and deceleration. It has shown good test-retested reliability in stroke patients.

The functional mobility will be assessed by the 10-m walk test. Participants will be instructed to walk without assistance for a 10-m distance in a solid flooring with a clear pathway. A mark at 2-m and 8-m will be placed. A stopwatch will be timed central 6-m to assess participants' acceleration and deceleration. It has shown good test-retested reliability in stroke patients.

The functional mobility will be assessed by the 10-m walk test. Participants will be instructed to walk without assistance for a 10-m distance in a solid flooring with a clear pathway. A mark at 2-m and 8-m will be placed. A stopwatch will be timed central 6-m to assess participants' acceleration and deceleration. It has shown good test-retested reliability in stroke patients.

The functional mobility will be assessed by the 10-m walk test. Participants will be instructed to walk without assistance for a 10-m distance in a solid flooring with a clear pathway. A mark at 2-m and 8-m will be placed. A stopwatch will be timed central 6-m to assess participants' acceleration and deceleration. It has shown good test-retested reliability in stroke patients.

The walking mobility will be assessed by the Time up and go test. During the test, participants will be instructed to stand up from the chair, walk forward for 3-meter, turn around 180 degrees, walk back, and sit on the chair. The time taken to complete this task will be measured via stopwatch. The test has shown good test-retested reliability in stroke patients.

The walking mobility will be assessed by the Time up and go test. During the test, participants will be instructed to stand up from the chair, walk forward for 3-meter, turn around 180 degrees, walk back, and sit on the chair. The time taken to complete this task will be measured via stopwatch. The test has shown good test-retested reliability in stroke patients.

The walking mobility will be assessed by the Time up and go test. During the test, participants will be instructed to stand up from the chair, walk forward for 3-meter, turn around 180 degrees, walk back, and sit on the chair. The time taken to complete this task will be measured via stopwatch. The test has shown good test-retested reliability in stroke patients.

The walking mobility will be assessed by the Time up and go test. During the test, participants will be instructed to stand up from the chair, walk forward for 3-meter, turn around 180 degrees, walk back, and sit on the chair. The time taken to complete this task will be measured via stopwatch. The test has shown good test-retested reliability in stroke patients.

The lower limb muscle strength of affected and unaffected ankle dorsiflexors and plantar flexors will be assessed by the hand-held dynamometer (Lafayette Hand-held Dynamometer Model 1165A, Lafayette Instrument Evaluation, Lafayette, Indiana, USA). The subjects will be asked to perform in the supine position. The hand-held dynamometer was positioned anteriorly or posteriorly over the heads of the first to fifth metatarsal bones to measure the strength of the ankle dorsiflexors and plantar flexors, respectively. Subjects were placed in the supine position and asked to perform the MIVC for 3 s. Each muscle group was tested twice by the same rater, with at least 30 s of rest between the two trials to reduce the effects of fatigue. The averages of the MIVC in kilograms were used in statistical analysis. The dynamometer used in the trials was shown to have excellent inter-rater reliability and test-retest reliability in community-dwelling older adults.

The lower limb muscle strength of affected and unaffected ankle dorsiflexors and plantar flexors will be assessed by the hand-held dynamometer (Lafayette Hand-held Dynamometer Model 1165A, Lafayette Instrument Evaluation, Lafayette, Indiana, USA). The subjects will be asked to perform in the supine position. The hand-held dynamometer was positioned anteriorly or posteriorly over the heads of the first to fifth metatarsal bones to measure the strength of the ankle dorsiflexors and plantar flexors, respectively. Subjects were placed in the supine position and asked to perform the MIVC for 3 s. Each muscle group was tested twice by the same rater, with at least 30 s of rest between the two trials to reduce the effects of fatigue. The averages of the MIVC in kilograms were used in statistical analysis. The dynamometer used in the trials was shown to have excellent inter-rater reliability and test-retest reliability in community-dwelling older adults.

The lower limb muscle strength of affected and unaffected ankle dorsiflexors and plantar flexors will be assessed by the hand-held dynamometer (Lafayette Hand-held Dynamometer Model 1165A, Lafayette Instrument Evaluation, Lafayette, Indiana, USA). The subjects will be asked to perform in the supine position. The hand-held dynamometer was positioned anteriorly or posteriorly over the heads of the first to fifth metatarsal bones to measure the strength of the ankle dorsiflexors and plantar flexors, respectively. Subjects were placed in the supine position and asked to perform the MIVC for 3 s. Each muscle group was tested twice by the same rater, with at least 30 s of rest between the two trials to reduce the effects of fatigue. The averages of the MIVC in kilograms were used in statistical analysis. The dynamometer used in the trials was shown to have excellent inter-rater reliability and test-retest reliability in community-dwelling older adults.

The lower limb muscle strength of affected and unaffected ankle dorsiflexors and plantar flexors will be assessed by the hand-held dynamometer (Lafayette Hand-held Dynamometer Model 1165A, Lafayette Instrument Evaluation, Lafayette, Indiana, USA). The subjects will be asked to perform in the supine position. The hand-held dynamometer was positioned anteriorly or posteriorly over the heads of the first to fifth metatarsal bones to measure the strength of the ankle dorsiflexors and plantar flexors, respectively. Subjects were placed in the supine position and asked to perform the MIVC for 3 s. Each muscle group was tested twice by the same rater, with at least 30 s of rest between the two trials to reduce the effects of fatigue. The averages of the MIVC in kilograms were used in statistical analysis. The dynamometer used in the trials was shown to have excellent inter-rater reliability and test-retest reliability in community-dwelling older adults.

The general fatigue will be assessed by The Fatigue Assessment Scale. It is a 10-item survey, of which 5 items assess physical fatigue and the remaining 5 items assess mental fatigue. The total score ranges from 10 to 50, and a total score ≥ 22 indicates fatigue. The translated Chinese version will be used in the proposed study.

The general fatigue will be assessed by The Fatigue Assessment Scale. It is a 10-item survey, of which 5 items assess physical fatigue and the remaining 5 items assess mental fatigue. The total score ranges from 10 to 50, and a total score ≥ 22 indicates fatigue. The translated Chinese version will be used in the proposed study.

The general fatigue will be assessed by The Fatigue Assessment Scale. It is a 10-item survey, of which 5 items assess physical fatigue and the remaining 5 items assess mental fatigue. The total score ranges from 10 to 50, and a total score ≥ 22 indicates fatigue. The translated Chinese version will be used in the proposed study.

The general fatigue will be assessed by The Fatigue Assessment Scale. It is a 10-item survey, of which 5 items assess physical fatigue and the remaining 5 items assess mental fatigue. The total score ranges from 10 to 50, and a total score ≥ 22 indicates fatigue. The translated Chinese version will be used in the proposed study.

Participants' mood will be measured by the Depression Anxiety Stress Scale, a 21-item survey that assesses depression, anxiety, and stress. Each index (i.e., depression, anxiety, and stress) comprises seven items. The scores ranges from 0 to 42. Higher score indicates more sever symptom. The reliability of this scale was confirmed in previous research.

Participants' mood will be measured by the Depression Anxiety Stress Scale, a 21-item survey that assesses depression, anxiety, and stress. Each index (i.e., depression, anxiety, and stress) comprises seven items. The scores ranges from 0 to 42. Higher score indicates more sever symptom. The reliability of this scale was confirmed in previous research.

Participants' mood will be measured by the Depression Anxiety Stress Scale, a 21-item survey that assesses depression, anxiety, and stress. Each index (i.e., depression, anxiety, and stress) comprises seven items. The scores ranges from 0 to 42. Higher score indicates more sever symptom. The reliability of this scale was confirmed in previous research.

Participants' mood will be measured by the Depression Anxiety Stress Scale, a 21-item survey that assesses depression, anxiety, and stress. Each index (i.e., depression, anxiety, and stress) comprises seven items. The scores ranges from 0 to 42. Higher score indicates more sever symptom. The reliability of this scale was confirmed in previous research.

The Natural Oscillation Frequency will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Natural Oscillation Frequency will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Natural Oscillation Frequency will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Natural Oscillation Frequency will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Health-related Quality of Life will be assessed by the 12-item Short-Form Survey (SF-12). This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better QoL.

The Health-related Quality of Life will be assessed by the 12-item Short-Form Survey (SF-12). This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better QoL.

The Health-related Quality of Life will be assessed by the 12-item Short-Form Survey (SF-12). This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better QoL.

The Health-related Quality of Life will be assessed by the 12-item Short-Form Survey (SF-12). This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better QoL.

The Dynamic Stiffness will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Dynamic Stiffness will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Dynamic Stiffness will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Dynamic Stiffness will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Logarithmic Decrement of natural oscillation will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Logarithmic Decrement of natural oscillation will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Logarithmic Decrement of natural oscillation will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Logarithmic Decrement of natural oscillation will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Mechanical Stress Relaxation Time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Mechanical Stress Relaxation Time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Mechanical Stress Relaxation Time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Mechanical Stress Relaxation Time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Ratio of deformation and Relaxation time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Ratio of deformation and Relaxation time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Ratio of deformation and Relaxation time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.

The Ratio of deformation and Relaxation time will be used to assess the muscle stiffness. The muscle stiffness of the affected and unaffected lower limb will be assessed by a hand-held digit palpation device, MyotoPRO (Myoton AS, Tallinn, Estonia). The subject will be asked to perform in the sitting position with hip flexion 90°, knee flexion 90°. The standard probe was placed perpendicularly to the skin's surface of the affected and unaffected tibial anterior and medial gastrocnemius directly. An initial force was exerted; then, an additional mechanical force was applied to the subcutaneous tissue for 15 milliseconds, which induced muscle deformation. The resultant damped natural oscillations caused by the viscoelastic properties of the soft tissue were recorded using a built-in accelerometer at a sampling rate of 3200 Hz.