Effectiveness of Robot-Assisted Structured Foot-Ankle Sensorimotor Training in Stroke Patients

Walking speed will be assessed using the 10-Meter Walk Test (10MWT). The test will be performed on a 14-m flat, unobstructed walkway including 2-m acceleration and 2-m deceleration distances. Time (s) will be recorded between 2 and 12 m using a stopwatch (dynamic start method), and walking speed (m/s) will be calculated as 10 m divided by the recorded time. Participants may use their customary walking aids. The test will be performed three times, and the mean walking speed will be used for analysis.

The test will be performed separately for each limb; three trials will be recorded per limb and averaged (s). Testing will occur on a flat, non-slip surface in a safe and quiet environment. Timing will start when the foot is fully lifted and stop when balance is lost, the foot touches down, or support is used.

Ankle joint position sense (JPS) accuracy will be assessed using a standardized electrogoniometer-based protocol. Participants will identify previously presented ankle dorsiflexion target positions while visual input is eliminated. JPS accuracy will be quantified as the absolute error (AE) between the target angle and the perceived angle, with lower values indicating better proprioceptive performance. Measurements will be obtained from repeated trials and averaged to generate a total AE score.

Assessment of satisfaction with the robot: This will be assessed using a Quest-Likert scale. A 4-point Likert scale will be used for assessment. It is a survey methodology using four response options. Stroke patients express their level of satisfaction by selecting one of four options: 1 Strongly Disagree, 2 Disagree, 3 Agree, and 4 Strongly Agree. A higher score will be interpreted as increased satisfaction and positive patient progress.

The Stroke-Specific Quality of Life Scale (SS-QOL) will be used to assess quality of life. The SS-QOL is a valid and reliable instrument comprising 12 domains and 49 items, covering the physical, functional, and psychosocial aspects of individuals after stroke. Assessments will be conducted in a quiet environment based on participants' self-reports, with items scored using a 5-point Likert scale. Total scores range from 49 to 245, with higher scores indicating better quality of life. The scale will be administered before and after the intervention, and changes in total and/or subscale scores will be used for analysis.

Tactile perception will be assessed using the The Semmes-Weinstein Monofilament Test. Five monofilaments will be applied to plantar (7 points) and dorsal (2 points) regions; analyses will use changes in the corresponding force (g) values. Participants will be supine with eyes closed. The monofilament will be applied perpendicular to the skin for ~1-1.5 s; three repetitions will be performed at each point and responses recorded verbally.

Walking capacity will also be assessed using the 2-Minute Walk Test (2MWT) distance (m). Participants will walk for 120 s at a self-selected, comfortable, and safe pace. Customary walking aids may be used if needed, but no manual assistance will be provided. Rest breaks will be allowed; however, the timer will continue uninterrupted. The total distance covered will be recorded in meters.

Motor performance will be assessed using the Fugl-Meyer Assessment for the Lower Extremity (FMA-LE). The FMA-LE evaluates hip, knee, and ankle motor function across reflex activity, synergies, selective movements, and coordination/speed. Items are scored 0-2 (total 0-34), with higher scores indicating better motor function. Assessments will be conducted in a standardized, quiet environment using standardized verbal instructions in supine, sitting, or standing positions as required by the test.

Dynamic balance and functional mobility will be assessed using the Timed Up and Go (TUG) test. The time (s) required to stand from a chair, walk 3 m, turn, return, and sit will be recorded. Participants may use their habitual walking aids if needed; no manual assistance will be provided. Three trials will be averaged.

Muscle tone will be assessed using the Modified Ashworth Scale (MAS) for the quadriceps, hamstrings, adductors, and gastrosoleus. MAS scores range from 0 to 4 (including 1+), with lower scores indicating less spasticity: 0 (no increase in tone), 1 (slight increase in tone), 1+ (marked resistance through less than half of the ROM), 2 (increased tone through most of the ROM), 3 (considerable increase in tone making passive movement difficult), and 4 (rigidity). Assessments will be performed with a single, rapid passive movement through ROM with the participant relaxed.

Passive and active ankle ROM will be assessed using an electrogoniometer. Participants will be positioned on an examination plinth with the hip and knee flexed to 90°, tibiae perpendicular to the floor, and feet unsupported. Neutral ankle position will be defined as 0° (foot perpendicular to the tibia). For dorsiflexion-plantarflexion measurements, the axis will be aligned with the lateral malleolus, the proximal reference with the lateral midline of the fibula, and the distal reference with the lateral midline of the fifth metatarsal. The rearfoot will be stabilized to minimize inversion/eversion during testing.

The Mini Balance Evaluation Systems Test (Mini-BESTest) will assess dynamic balance across anticipatory postural adjustments, reactive postural control, sensory orientation, and dynamic gait. Each of the 14 items is scored 0-2 (total 0-28), with higher scores indicating better balance.