The influence of locomotor training on dynamic balance during steady-state walking post-stroke

Slow walking speed and lack of balance control are common impairments post-stroke. While locomotor training often improves walking speed, its influence on dynamic balance is unclear. The goal of this study was to assess the influence of a locomotor training program on dynamic balance in individuals post-stroke during steady-state walking and determine if improvements in walking speed are associated with improved balance control. Kinematic and kinetic data were collected pre- and post-training from seventeen participants who completed a 12-week locomotor training program. Dynamic balance was quantified biomechanically (peak-to-peak range of frontal plane whole-body angular-momentum) and clinically (Berg-Balance-Scale and Dynamic-Gait-Index). To understand the underlying biomechanical mechanisms associated with changes in angular-momentum, foot placement and ground-reaction-forces were quantified. As a group, biomechanical assessments of dynamic balance did not reveal any improvements after locomotor training. However, improved dynamic balance post-training, observed in a sub-group of 10 participants (i.e., Responders), was associated with a narrowed paretic foot placement and higher paretic leg vertical ground-reaction-force impulse during late stance. Dynamic balance was not improved post-training in the remaining seven participants (i.e., Non-responders), who did not alter their foot placement and had an increased reliance on their nonparetic leg during weight-bearing. As a group, increased walking speed was not correlated with improved dynamic balance. However, a higher pre-training walking speed was associated with higher gains in dynamic balance post-training. These findings highlight the importance of the paretic leg weight bearing and mediolateral foot placement in improving frontal plane dynamic balance post-stroke.     

Control of lateral weight transfer is associated with walking speed in individuals post-stroke

Restoring functional gait speed is an important goal for rehabilitation post-stroke. During walking, transferring of one’s body weight between the limbs and maintaining balance stability are necessary for independent functional gait. Although it is documented that individuals post-stroke commonly have difficulties with performing weight transfer onto their paretic limbs, it remains to be determined if these deficits contributed to slower walking speeds. The primary purpose of this study was to compare the weight transfer characteristics between slow and fast post-stroke ambulators. Participants (N = 36) with chronic post-stroke hemiparesis walked at their comfortable and maximal walking speeds on a treadmill. Participants were stratified into 2 groups based on their comfortable walking speeds (≥0.8 m/s or <0.8 m/s). Minimum body center of mass (COM) to center of pressure (COP) distance, weight transfer timing, step width, lateral foot placement relative to the COM, hip moment, peak vertical and anterior ground reaction forces, and changes in walking speed were analyzed. Results showed that slow walkers walked with a delayed and deficient weight transfer to the paretic limb, lower hip abductor moment, and more lateral paretic limb foot placement relative to the COM compared to fast walkers. In addition, propulsive force and walking speed capacity was related to lateral weight transfer ability. These findings demonstrated that deficits in lateral weight transfer and stability could potentially be one of the limiting factors underlying comfortable walking speeds and a determinant of chronic stroke survivors’ ability to increase walking speed.     

Changes in lower limb muscle activity after walking on a split-belt treadmill in individuals post-stroke

Background: There is growing evidence that stroke survivors can adapt and improve step length symmetry in the context of split-belt treadmill (SBT) walking. However, less knowledge exists about the strategies involved for such adaptations. This study analyzed lower limb muscle activity in individuals post-stroke related to SBT-induced changes in step length. Methods: Step length and surface EMG activity of six lower limb muscles were evaluated in individuals post-stroke (n = 16) during (adaptation) and after (after-effects) walking at unequal belt speeds. Results: During adaptation, significant increases in EMG activity were mainly found in proximal muscles (p ⩽ 0.023), whereas after-effects were observed particularly in the distal muscles. The plantarflexor EMG increased after walking on the slow belt (p ⩽ 0.023) and the dorsiflexors predominantly after walking on the fast belt (p ⩽ 0.017) for both, non-paretic and paretic-fast conditions. Correlation analysis revealed that after-effects in step length were mainly associated with changes in distal paretic muscle activity (0.522 ⩽ r ⩽ 0.663) but not with functional deficits. Based on our results, SBT walking could be relevant for training individuals post-stroke who present shorter paretic step length combined with dorsiflexor weakness, or individuals with shorter nonparetic step length and plantarflexor weakness.     

Muscle contributions to mediolateral and anteroposterior foot placement during walking

Foot placement is critical to balance control during walking and is primarily controlled by muscle force generation. Although gluteus medius activity has been associated with mediolateral foot placement, how other muscles contribute to foot placement is not clear. Furthermore, although dynamic walking models have suggested that anteroposterior foot placement can be passively controlled, the extent to which muscles actively contribute to anteroposterior foot placement has not been determined. The objective of this study was to identify individual muscle contributions to mediolateral and anteroposterior foot placement during walking in healthy adults. Dynamic simulations of walking were developed for six older adults and a segmental power analysis was performed to determine the individual muscle contributions to the mediolateral and anteroposterior power delivered to the foot segment. The simulations revealed the ipsilateral swing limb gluteus medius, iliopsoas, rectus femoris and hamstrings and the contralateral stance limb gluteus medius and ankle plantarflexors were primary contributors to both mediolateral and anteroposterior foot placement. Muscle contributions to foot placement were found to be highly influenced by their contributions to pelvis power, which was dominated by those muscles crossing the hip joint. Thus, impaired balance control may be improved by focusing rehabilitation interventions on optimizing the coordination of those muscles crossing the hip joint and the ankle plantarflexors.     

Merged plantarflexor muscle activity is predictive of poor walking performance in post-stroke hemiparetic subjects

Stroke is the leading cause of long-term disability and individuals post-stroke often experience impaired walking ability. The plantarflexor (PF) muscles are critical to walking through their contributions to the ground reaction forces and body segment energetics. Previous studies have shown muscle activity during walking can be grouped into co-excited muscle sets, or modules. Improper co-activation, or merging of modules, is a common impairment in individuals post-stroke. The purpose of this study was to determine the influence of merged PF modules on walking performance in individuals post stroke by examining balance control, body support and propulsion, and walking symmetry. Muscle modules were identified using non-negative matrix factorization to classify subjects as having an independent or merged PF module. The merged group had decreased balance control with a significantly higher frontal plane whole-body angular momentum than both the independent and control groups, while the independent and control groups were not significantly different. The merged group also had higher paretic braking and nonparetic propulsion than both the independent and control groups. These results remained when comparisons were limited to subjects who had the same number of modules, indicating this was not a general effect due to subjects with merged PF having fewer modules. It is likely that a merged PF module is indicative of general PF dysfunction even when some activation occurs at the appropriate time. These results suggest an independent PF module is critical to walking performance, and thus obtaining an independent PF module should be a crucial aim of stroke rehabilitation.     

The effects of walking speed on obstacle crossing in healthy young and healthy older adults

The effects of walking speed and age on the peak external moments generated about the joints of the trailing limb during stance just prior to stepping over an obstacle and on the kinematics of the trailing limb when crossing the obstacle were investigated in 10 healthy young adults (YA) and 10 healthy older adults (OA). The peak hip and knee adduction moments in OA were 21-43% greater than those in YA (p相似文献   

Joint moments’ contributions to vertically accelerate the center of mass during stair ambulation in the elderly: An induced acceleration approach

Falls are a serious problem faced by the elderly. Older adults report mostly to fall while performing locomotor activities, especially the ones requiring stair negotiation. During these tasks, older adults, when compared with young adults, seem to redistribute their lower limb joint moments. This may indicate that older adults use a different strategy to accelerate the body upward during these tasks. The purposes of this study were to quantify the contributions of each lower limb joint moment to vertically accelerate the center of mass during stair ascent and descent, in a sample of community-dwelling older adults, and to verify if those contributions were correlated with age and functional fitness level. A joint moment induced acceleration analysis was performed in 29 older adults while ascending and descending stairs at their preferred speed. Agreeing with previous studies, during both tasks, the ankle plantarflexor and the knee extensor joint moments were the main contributors to support the body. Although having a smaller contribution to vertically accelerate the body, during stair descent, the hip joint moment contribution was related with the balance score. Further, older adults, when compared with the results reported previously for young adults, seem to use more their knee extensor moment than the ankle plantarflexor moment to support the body when the COM downward velocity is increasing. By contributing for a better understanding of stair negotiation in community dwelling older adults, this study may help to support the design of interventions aiming at fall prevention and/or mobility enhancement within this population.     

Muscle contributions to support during gait in an individual with post-stroke hemiparesis

Walking requires coordination of muscles to support the body during single stance. Impaired ability to coordinate muscles following stroke frequently compromises walking performance and results in extremely low walking speeds. Slow gait in post-stroke hemiparesis is further complicated by asymmetries in lower limb muscle excitations. The objectives of the current study were: (1) to compare the muscle coordination patterns of an individual with flexed stance limb posture secondary to post-stroke hemiparesis with that of healthy adults walking very slowly, and (2) to identify how paretic and non-paretic muscles provide support of the body center of mass in this individual. Simulations were generated based on the kinematics and kinetics of a stroke survivor walking at his self-selected speed (0.3 m/s) and of three speed-matched, healthy older individuals. For each simulation, muscle forces were perturbed to determine the muscles contributing most to body weight support (i.e., height of the center of mass during midstance). Differences in muscle excitations and midstance body configuration caused paretic and non-paretic ankle plantarflexors to contribute less to midstance support than in healthy slow gait. Excitation of paretic ankle dorsiflexors and knee flexors during stance opposed support and necessitated compensation by knee and hip extensors. During gait for an individual with post-stroke hemiparesis, adequate body weight support is provided via reorganized muscle coordination patterns of the paretic and non-paretic lower limbs relative to healthy slow gait.     

The differences in sagittal plane whole-body angular momentum during gait between patients with hemiparesis and healthy people

Regulation of whole-body angular momentum (WBAM) is essential for maintaining dynamic balance during gait. Patients with hemiparesis frequently fall toward the anterior direction; however, whether this is due to impaired WBAM control in the sagittal plane during gait remains unknown. The present study aimed to investigate the differences in WBAM in the sagittal plane during gait between patients with hemiparesis and healthy individuals. Thirty-three chronic stroke patients with hemiparesis and twenty-two age- and gender-matched healthy controls walked along a 7-m walkway while gait data were recorded using a motion analysis system and force plates. WBAM and joint moment were calculated in the sagittal plane during each gait cycle. The range of WBAM in the sagittal plane in the second half of the paretic gait cycle was significantly larger than that in the first and second halves of the right gait cycle in the controls (P = 0.015 and P = 0.011). Furthermore, multiple regression analysis revealed the slower walking speed (P < 0.001) and larger knee extension moment on the non-paretic side (P = 0.003) contributed to the larger range of WBAM in the sagittal plane in the second half of the paretic gait cycle. Our findings suggest that dynamic stability in the sagittal plane is impaired in the second half of the paretic gait cycle. In addition, the large knee extension moment on the non-paretic side might play a role in the dynamic instability in the sagittal plane during gait in patients with hemiparesis.     

Impaired Limb Shortening following Stroke: What’s in a Name?

Background

Difficulty advancing the paretic limb during the swing phase of gait is a prominent manifestation of walking dysfunction following stroke. This clinically observable sign, frequently referred to as ‘foot drop’, ostensibly results from dorsiflexor weakness.

Objective

Here we investigated the extent to which hip, knee, and ankle motions contribute to impaired paretic limb advancement. We hypothesized that neither: 1) minimal toe clearance and maximal limb shortening during swing nor, 2) the pattern of multiple joint contributions to toe clearance and limb shortening would differ between post-stroke and non-disabled control groups.

Methods

We studied 16 individuals post-stroke during overground walking at self-selected speed and nine non-disabled controls who walked at matched speeds using 3D motion analysis.

Results

No differences were detected with respect to the ankle dorsiflexion contribution to toe clearance post-stroke. Rather, hip flexion had a greater relative influence, while the knee flexion influence on producing toe clearance was reduced.

Conclusions

Similarity in the ankle dorsiflexion, but differences in the hip and knee, contributions to toe clearance between groups argues strongly against dorsiflexion dysfunction as the fundamental impairment of limb advancement post-stroke. Marked reversal in the roles of hip and knee flexion indicates disruption of inter-joint coordination, which most likely results from impairment of the dynamic contribution to knee flexion by the gastrocnemius muscle in preparation for swing. These findings suggest the need to reconsider the notion of foot drop in persons post-stroke. Redirecting the focus of rehabilitation and restoration of hemiparetic walking dysfunction appropriately, towards contributory neuromechanical impairments, will improve outcomes and reduce disability.     

Age-related reduction in sagittal plane center of mass motion during obstacle crossing

Accidental falls are a leading cause of injury and death in the growing elderly population. Traumatic falls are frequent, costly, and debilitating. Control of balance during locomotion is critical for safe ambulation, but relatively little is known about the natural effect of aging on dynamic balance control. Samples of healthy young (n = 13) and elderly (n = 13) subjects were compared in the interactive measures of center of mass (COM) and center of pressure (COP) during level walking and obstacle crossing conditions. Obstacle heights were normalized to individual body height (2.5%, 5%, 10%, and 15%). Temporal-distance (T-D) variables of gait were also compared. Statistical analyses were conducted using a two-way ANOVA for subject group and obstacle height. T-D parameters were not significantly different between groups; nor were frontal plane COM and COP parameters. Significant age differences did exist for antero-posterior (A/P) motion of the COM (decreased motion in the elderly), and its relationship with the COP (reduced separation between the two variables in the elderly). Anterior COM velocities were also significantly lower in the elderly group. The results confirm the ability of healthy elderly adults to maintain dynamic balance control in the frontal plane during locomotion. Reduced A/P distances between the COM and COP indicate a conservative reduction of the mechanical load on joints of the supporting limb. This conservative strategy may be related to a reduction in muscle strength as it occurs in the natural aging process.     

Hip recovery strategy used by below-knee amputees following mediolateral foot perturbations

Lower-limb amputees have a higher risk of falling compared to non-amputees. Proper regulation of whole-body angular momentum is necessary to prevent falls, particularly in the frontal plane where individuals are most unstable. However, the balance recovery mechanisms used by lower-limb amputees when recovering from a perturbation are not well-understood. This study sought to understand the balance recovery mechanisms used by lower-limb amputees in response to mediolateral foot perturbations by examining changes to frontal plane whole-body angular momentum and hip joint work. These metrics provide a quantitative measure of frontal plane dynamic balance and associated joint contributions required to maintain balance during gait. Nine amputees and 11 non-amputees participated in this study where an unexpected medial or lateral foot placement perturbation occurred immediately prior to heel strike on the residual, sound or non-amputee limbs. Lateral perturbations of all limbs resulted in a reduced range of whole-body angular momentum and increased positive frontal plane hip work in the first half of single limb support. Medial perturbations for all limbs resulted in increased range of whole-body angular momentum and decreased positive frontal plane hip work, also in the first half of single limb support. These results suggest that medial foot placement perturbations are particularly challenging and that hip strategies play an important role in balance recovery. Thus, rehabilitation interventions that focus on hip muscles that regulate mediolateral balance, particularly the hip abductors, and the use of prostheses with active ankle control, may reduce the risk of falls.     

Lower-limb amputee recovery response to an imposed error in mediolateral foot placement

Despite walking with a wider step width, amputees remain 20% more likely to fall than non-amputees. Since mediolateral (ML) balance is critical for ambulation and contingent on ML foot placement, we used a ML disturbance to perturb walking balance and explore the influence of prosthetic foot stiffness on balance recovery. Ten transtibial amputees were fit with two commonly prescribed prosthetic feet with differing stiffness characteristics; 12 non-amputees also participated. A perturbation device that released an air burst just before heel strike imposed a repeatable medial or lateral disturbance in foot placement. After a medial disturbance, the first recovery step width was narrowed (p<0.0001) for the prosthetic limb (−103%), the sound limb (−51%) and non-amputees (−41%) and more than twice as variable. The ML inclination angle remained reduced (−109%) for the prosthetic limb, while the sound limb and non-amputees approached undisturbed levels (p<0.0004). Amputees required five steps to return to undisturbed step width after a prosthetic medial disturbance versus two steps for the sound limb and for non-amputees. After a lateral disturbance, the first recovery step was widened for the prosthetic limb (+82%), sound limb (+75%), and wider than non-amputees (+51%; p<0.0001), with all participants requiring three steps to return to undisturbed step width. Amputees also exhibited a similar upper torso response compared to the non-amputees for both disturbances. Prosthetic feet with different stiffness properties did not have a significant effect. In conclusion, amputee balance was particularly challenged by medial disturbances to the prosthetic limb implying a need for improved interventions that address these balance deficits.     

Dynamic structure of lower limb joint angles during walking post-stroke

BackgroundVariability in joint kinematics is necessary for adaptability and response to everyday perturbations; however, intrinsic neuromotor changes secondary to stroke often cause abnormal movement patterns. How these abnormal movement patterns relate to joint kinematic variability and its influence on post-stroke walking impairments is not well understood.ObjectiveThe purpose of this study was to evaluate the movement variability at the individual joint level in the paretic and non-paretic limbs of individuals post-stroke.MethodsSeven individuals with hemiparesis post-stroke walked on a treadmill for two minutes at their self-selected speed and the average speed of the six-minute walk test while kinematics were recorded using motion-capture. Variability in hip, knee, and ankle flexion/extension angles during walking were quantified with the Lyapunov exponent (LyE). Interlimb differences were evaluated.ResultsThe paretic side LyE was higher than the non-paretic side at both self-selected speed (Hip: 50%; Knee: 74%), and the average speed of the 6-min walk test (Hip: 15%; Knee: 93%).ConclusionDifferences in joint kinematic variability between limbs of persons post-stroke supports further study of the source of non-paretic limb deviations as well as the clinical implications of joint kinematic variability in persons post-stroke. The development of bilaterally-targeted post-stroke gait interventions to address variability in both limbs may promote improved outcomes.     

Joint moment work during the stance-to-swing transition in hemiparetic subjects

Following stroke many individuals are left with neurological and functional deficits, including hemiparesis, which impair their ability to walk. Our previous work reported that propulsion of the paretic leg during pre-swing is impaired and may limit gait speed and knee flexion during swing. To elucidate the mechanism of this impairment, we assessed the mechanical work produced by the hip, knee, and ankle moments during pre-swing of the paretic limb in a group of stroke subjects and compared it with the work produced by non-disabled controls walking at similar speeds. Kinematic and kinetic gait data were collected from 23 hemiparetic and 10 control subjects. The hemiparetic subjects walked at their self-selected speeds. The controls walked at their self-selected and two or three slower speeds. Even when compared to controls walking at slow speeds, ankle plantarflexor work during pre-swing was greatly reduced (-0.136+/-0.062J/kg) in the hemiparetic subjects. Differences in hip (+0.006+/-0.020J/kg) and knee (+0.040+/-0.026J/kg) moment work partially offset the reduction in ankle work, but net joint moment work was still significantly reduced (-0.088+/-0.056J/kg). The reduction in work accounts for the low energy of the paretic limb at the stance-to-swing transition previously reported. Future investigation is needed to determine if targeted training of the plantarflexors in the paretic limb improves swing-phase function and locomotor performance in hemiparetic individuals.     

Stepping in the direction of the fall: the next foot placement can be predicted from current upper body state in steady-state walking

During human walking, perturbations to the upper body can be partly corrected by placing the foot appropriately on the next step. Here, we infer aspects of such foot placement dynamics using step-to-step variability over hundreds of steps of steady-state walking data. In particular, we infer dependence of the ‘next’ foot position on upper body state at different phases during the ‘current’ step. We show that a linear function of the hip position and velocity state (approximating the body center of mass state) during mid-stance explains over 80% of the next lateral foot position variance, consistent with (but not proving) lateral stabilization using foot placement. This linear function implies that a rightward pelvic deviation during a left stance results in a larger step width and smaller step length than average on the next foot placement. The absolute position on the treadmill does not add significant information about the next foot relative to current stance foot over that already available in the pelvis position and velocity. Such walking dynamics inference with steady-state data may allow diagnostics of stability and inform biomimetic exoskeleton or robot design.     

Biomechanical impairments and gait adaptations post-stroke: Multi-factorial associations

Understanding the potential causes of both reduced gait speed and compensatory frontal plane kinematics during walking in individuals post-stroke may be useful in developing effective rehabilitation strategies. Multiple linear regression analysis was used to select the combination of paretic limb impairments (frontal and sagittal plane hip strength, sagittal plane knee and ankle strength, and multi-joint knee/hip torque coupling) which best estimate gait speed and compensatory pelvic obliquity velocities at toeoff. Compensatory behaviors were defined as deviations from control subjects’ values. The gait speed model (n=18; p=0.003) revealed that greater hip abduction strength and multi-joint coupling of sagittal plane knee and frontal plane hip torques were associated with decreased velocity; however, gait speed was positively associated with paretic hip extension strength. Multi-joint coupling was the most influential predictor of gait speed. The second model (n=15; p<0.001) revealed that multi-joint coupling was associated with increased compensatory pelvic movement at toeoff; while hip extension and flexion and knee flexion strength were associated with reduced frontal plane pelvic compensations. In this case, hip extension strength had the greatest influence on pelvic behavior. The analyses revealed that different yet overlapping sets of single joint strength and multi-joint coupling measures were associated with gait speed and compensatory pelvic behavior during walking post-stroke. These findings provide insight regarding the potential impact of targeted rehabilitation paradigms on improving speed and compensatory kinematics following stroke.     

EMG synchrony to assess impaired corticomotor control of locomotion after stroke

Adapting one’s gait pattern requires a contribution from cortical motor commands. Evidence suggests that frequency-based analysis of electromyography (EMG) can be used to detect this cortical contribution. Specifically, increased EMG synchrony between synergistic muscles in the Piper frequency band has been linked to heightened corticomotor contribution to EMG. Stroke-related damage to cerebral motor pathways would be expected to diminish EMG Piper synchrony. The objective of this study is therefore to test the hypothesis that EMG Piper synchrony is diminished in the paretic leg relative to nonparetic and control legs, particularly during a long-step task of walking adaptability. Twenty adults with post-stroke hemiparesis and seventeen healthy controls participated in this study. EMG Piper synchrony increased more for the control legs compare to the paretic legs when taking a non-paretic long step (5.02 ± 3.22% versus 0.86 ± 2.62%), p < 0.01) and when taking a paretic long step (2.04 ± 1.98% versus 0.70 ± 2.34%, p < 0.05). A similar but non-significant trend was evident when comparing non-paretic and paretic legs. No statistically significant differences in EMG Piper synchrony were found between legs for typical walking. EMG Piper synchrony was positively associated with walking speed and step length within the stroke group. These findings support the assertion that EMG Piper synchrony indicates corticomotor contribution to walking.     

Pre-swing deficits in forward propulsion,swing initiation and power generation by individual muscles during hemiparetic walking

Clinical studies of hemiparetic walking have shown pre-swing abnormalities in the paretic leg suggesting that paretic muscle contributions to important biomechanical walking subtasks are different than those of non-disabled individuals. Three-dimensional forward dynamics simulations of two representative hemiparetic subjects with different levels of walking function classified by self-selected walking speed (i.e., limited community=0.4–0.8 m/s and community walkers=>0.8 m/s) and a speed-matched control were generated to quantify individual muscle contributions to forward propulsion, swing initiation and power generation during the pre-swing phase (i.e., double support phase proceeding toe-off). Simulation analyses identified decreased paretic soleus and gastrocnemius contributions to forward propulsion and power generation as the primary impairment in the limited community walker compared to the control subject. The non-paretic leg did not compensate for decreased forward propulsion by paretic muscles during pre-swing in the limited community walker. Paretic muscles had the net effect to absorb energy from the paretic leg during pre-swing in the community walker suggesting that deficits in swing initiation are a primary impairment. Specifically, the paretic gastrocnemius and hip flexors (i.e., iliacus, psoas and sartorius) contributed less to swing initiation and the paretic soleus and gluteus medius absorbed more power from the paretic leg in the community walker compared to the control subject. Rehabilitation strategies aimed at diminishing these deficits have much potential to improve walking function in these hemiparetic subjects and those with similar deficits.     

Effects of passive Bi-axial ankle stretching while walking on uneven terrains in older adults with chronic stroke

Many people with stroke experience foot drop while walking. Further, walking on uneven surfaces is a common fall risk for these people that hinder with their daily life activities. In addition, a few years after a stroke, lower-limb exercises become less focused, especially the ankle joint movement. The objective of this study is to determine the gait performance of older adults with chronic stroke on an uneven surface in relation to ankle mobility after a four-week bi-axial ankle range of motion (ROM) exercise session. Fifteen older adults with chronic post-stroke hemiparesis (N = 15; mean age = 65 years) participated in a total of 12 bi-axial ankle ROM exercises that consisted of three 30-min training sessions per week for four weeks. Basic clinical tests and gait performance in even and uneven surfaces were evaluated before and after training. Participants with chronic post-stroke hemiparesis showed significantly improved ankle functions, decreased ankle stiffness (from 0.140 ± 0.059 to 0.128 ± 0.067 N·m/°; p = 0.025), and increased paretic ankle passive ROMs (dorsiflexion(DF)/plantarflexion(PF): from 27.3 ± 14.7° to 50.6 ± 10.3°, p < 0.001; inversion(INV)/eversion(EV): 21.7 ± 9.7° to 28.6 ± 9.9°; p = 0.033) after training. They exhibited significant improvements in the walking performance over an uneven surface, step kinematics (walking speed 0.257 ± 0.17 to 0.320 ± 0.178 m/s; p = 0.017; step length: 0.214 ± 0.109 to 0.243 ± 0.108 m; p = 0.009), and clinical balance and mobility (Berg balance scale: 47.2 ± 4.7 to 50.1 ± 3.9, p = 0.0001; timed-up and go test: 23.9 ± 10.3 to 20.2 ± 7.0 s, p = 0.0156). This study is the first research to investigate the walking performance on uneven surfaces in the elderly with chronic stroke in relation to the ankle biomechanical property changes.