Post on 18-Dec-2021
Gait Feature Vectors for Post-stroke Prediction using Wearable Sensor
Seunghee Hong1, Damee Kim2, Hongkyu Park3, Young Seo4,
Iqram Hussain5 Se Jin Park6†
Abstract
Stroke is a health problem experienced by many elderly people around the world. Stroke has a devastating effect
on quality of life, causing death or disability. Hemiplegia is clearly an early sign of a stroke and can be detected
through patterns of body balance and gait. The goal of this study was to determine various feature vectors of foot
pressure and gait parameters of patients with stroke through the use of a wearable sensor and to compare the gait
parameters with those of healthy elderly people. To monitor the participants at all times, we used a simple measuring
device rather than a medical device. We measured gait data of 220 healthy people older than 65 years of age and
of 63 elderly patients who had experienced stroke less than 6 months earlier. The center of pressure and the
acceleration during standing and gait-related tasks were recorded by a wearable insole sensor worn by the participants.
Both the average acceleration and the maximum acceleration were significantly higher in the healthy participants
(p < .01) than in the patients with stroke. Thus gait parameters are helpful for determining whether they are patients
with stroke or normal elderly people.
Key words: Gait Analysis, Health Monitoring System, Post-Stroke, Wearable Sensors
1. Introduction1)
The World Health Organization (WHO) defines
stroke as A stroke is caused by the interruption of the
blood supply to the brain, usually because a blood ves-
sel bursts or is blocked by a clot. This cuts off the sup-
ply of oxygen and nutrients, causing damage to the
brain tissue. Strokes are classified as ischemic stroke
which caused by inadequate supply of oxygen and nu-
trients in the blood after cerebrovascular blockage, and
Hemorrhagic stroke which caused by hematoma caused
by cerebral vascular injury. Risk factors of stroke onset
are known to be related to hypertension, diabetes, obe-
sity, dyslipidemia, etc. The Stroke Association recom-
1 Seunghee Hong: Senior Researcher, Center for Medical Convergence Metrology, KRISS2 Damee Kim: Researcher, Center for Medical Convergence Metrology, KRISS;
Researcher, Department of KSB Convergence Research, ETRI3 Hongkyu Park: Researcher, Department of KSB Convergence Research, ETRI4 Young Seo: Student Researcher, Center for Medical Convergence Metrology, KRISS5 Iqram Hussain: Student Researcher, Center for Medical Convergence Metrology, KRISS;
Student, Medical Physics, UST6 Se Jin Park: Head Researcher, Center for Medical Convergence Metrology, KRISS;
Head Researcher, Department of KSB Convergence Research, ETRI
Professor, Medical Physics, UST
†(Corresponding Author) Se Jin Park: Center for Medical Convergence Metrology, KRISS / E-mail:sjpark@kriss.re.kr /
TEL:042-868-5450
감성과학제22권 3호, 2019<연구논문>
pISSN 1226-8593eISSN 2383-613X
Sci. Emot. Sensib.,Vol.22, No.3, pp.55-64, 2019
https://doi.org/10.14695/KJSOS.2018.22.3.55
56 Seunghee Hong․Damee Kim․Hongkyu Park․Young Seo․Iqram Hussain․Se Jin Park
mends that it is important to identify and track patho-
physiologic risk factors with appropriate diagnostic
tests for recurrence and secondary prevention of stroke.
However, according to the Global Burden of Disease
(GBD) survey, the mortality rate of stroke among the
elderly over 70 years old was 7.76% in USA, 6.99%
in Germany, 9.47% in Japan and 13.02% in Korea
(GBD, 2017). It is difficult to directly compare the dif-
ference in race, culture, economic level and medical
level according to the region, but in Korea, the mortal-
ity rate due to stroke is significantly higher than in oth-
er countries. Symptoms and the severity after stroke
are determined by the position of the brain lesion and
the size of the lesion, but it is most important to treat
the specialist immediately after the onset. Furthermore,
due to this, the timing of appropriate treatment is
missed, increasing the patient's mortality rate and the
rate of disability. The typical clinical features of stroke
include hemiplegia, disturbance of sense, spasticity, in-
coordination, cognitive impairment, apraxia, hemi-
neglect, and dysphagia. In the early stages of stroke,
muscle weakness and decreased muscle tension lead to
paralysis. Among them, hemiplegia due to neuro-
logical disorders is very common in more than 80% of
stroke patients in general (Duncan et al., 2015).The
weakening of neurological muscular strength makes it
difficult for stroke patients to maintain the center of
the body in a static standing situation or to make nor-
mal walking (Duncan et al., 2015; Wevers et al.,
2009). The movement of the pressure center (center of
pressure, CoP) of the body in the static standing pos-
ture is being used as an evaluation tool to diagnose the
balance disorder (Bohannon, 1997). Gollhofer (1989)
and Horstmann (1990) reported that the trajectory of
the center of gravity (COG) gives information on the
control of the movements of the body necessary to
maintain a standing posture. While the trajectory of
difference of the center of pressure from the center of
gravity (COP-COG) presents the neuromuscular stiff-
ness of the biomechanical system controlling the center
of gravity. Moreover, Foot Pressure is and index to
evaluate the parameter of balance and walking. It may
cause musculoskeletal damage as well as physiological
disorders when foot pressure exceeds the normal range
(Yang et al., 2015).
Articulation in walking after a stroke involves a co-
operative pattern of lower limbs rather than selective
movement (Chen et al., 2005). Then, it adapts to a saf-
er and more stable walking pattern in order to magnify
the decrease of sensory information from the foot
(Yang et al., 2005). Insufficient single-leg support or
uncontrolled forward movement is considered a funda-
mental dysfunction leading to asymmetry. Asymmetry
consists of a decrease in stance period time and ex-
tension of swing leg period (Peter & Arthur, 2005).
Both leg support periods and stance periods are longer
than normal on both legs (Bohannon, 1986; Bohannon,
1987; Bohannon, 1991; Bohannon, 1997; Brandstater et
al., 1983; Nadeau et al., 1999; Nakamura et al., 1998).
Such asymmetry leads to an increase in energy costs,
falls, joint abnormalities, burden on joints, and pain
(Morris et al., 1986; Olney, 1969). Methods for meas-
uring such asymmetry are described in various
documents. The expression for obtaining temporal
asymmetry is calculated by dividing the value obtained
at the paralyzed side swing period / paralyzed side
stance period by the non-paralyzed side swing period /
non paralyzed side stance period time (Olney, 1969;
Patterson et al., 2010). The asymmetry of the single-leg
support time is obtained by 1-single-leg support time
(paralyzed side) / single leg support time (non-para-
lyzed side). The stride ratio is calculated by dividing
the stride (meters) on the paralyzed side by the non-
paralyzed side stride (meters) (Balasubramanian et al.,
2007). The larger these values, the more notable the
asymmetry is (Hsu, 2003). In stroke patients, the walk-
ing speed generally decreases. In a healthy subject, the
comfortable walking speed is about 1.3 m/s (Bohannon
Gait Feature Vectors for Post-stroke Prediction using Wearable Sensor 57
et al., 1997), and in a hemiplegic patient, the average
walking speed is set to 0.23 - 0.73 m/s (Olney &
Richards, 1996). Perry is classified into three according
to walking speed, and when it is less than 0.4 m / s
it is restricted to indoor movement, some restriction
occurs outdoors at 0.4 to 0.8 m / s, outdoor movement
is not restricted at 0.8 m / s or more It revealed that
(Perry, 1995).
According to the results of previous studies, body
balance and walking characteristics are obvious ob-
stacles caused by stroke. As mentioned above, quanti-
tative evaluation methods by the nervous system dam-
age after stroke onset can be measured, there aren’t
any systems monitoring and detecting the stroke fea-
tures when they are standing up and walking. In other
words, the delay in detection of a sympathetic post-
poned the treatment time of the stroke patients, thus
causing a fatal disorder or affecting the maintenance
of life.
Nevertheless, elder people have been still exposed
to the high risk of stroke should be monitored during
their daily activities and also the sensors and the deci-
sion making algorithms to detect their stroke symp-
toms are needed. At that reason, in this study, the dif-
ference in walking and standing characteristics be-
tween normal elderly and stroke patients is defined as
a feature vectors. And also, these results will be used
as a feature of the algorithm development that will be
applied to the stroke monitoring system during the
walk.
2. Methods
All experimental procedures were carried out after
approval of the institutional review board (KRISS-
IRB-2017-07).
2.1. Stroke Monitoring System
Our elderly health (stoke) monitoring system was de-
signed and suggested as shown in the Fig. 1 (Park et
al., 2017). Hyper-connected self-machine learning en-
gine controls the system. The elements of the system
are a knowledge base, big data, network security, re-
al-time data monitoring using wearables, and self-learn-
ing engine. The knowledge base would have risk fac-
tors, medical health records, psycho-logical factors, gait
Fig. 1. Components of the proposed elderly health (stoke) monitoring system
58 Seunghee Hong․Damee Kim․Hongkyu Park․Young Seo․Iqram Hussain․Se Jin Park
Fig. 2. System Framework for Stroke monitoring system during walking with wearable sensors
and motion patterns, and bio-signals. The old peoples’
activities, physiological, and bio signals are monitored
in real-time through wearable sensors. The self-ma-
chine learning engine would include multi-model learn-
ing (SVM, Bayes, RF, CNN, LSTM, deep learning)
and model generator. If the proposed system predicts
stroke symptom above 90%, it will generate an alarm
to family, the victim, people around the victim, and
healthcare professionals. Then the victim will get the
timely medical assistance. The Stroke Monitoring
System using gait parameters such as, insole foot pres-
sure and accelerometer, is proposed. Gait patterns such
as gait speed, foot pressure etc. of normal person and
stroke patient are significantly different from each
other. Wearable IoT (Internet of Things) devices and
statistical technique are able to detect stroke onset of
elderly adults. Entire system will feed subject’s physio-
logical data to cloud engine to compare real-time data
and reference data in order to detect stroke during gait
activities.
2.2. Subjects
220 normal elderly people over 65 years old and 63
elderly patients who were less than 6 months after the
onset of stroke participated in this study as in the Table
1. Study was performed in A National University
Hospital, Daejeon, South Korea. Healthy participants
were recruited to the elderly enrolled at the local silver
center, and patients were recruited for the elderly who
were in hospital or after rehabilitation. The stroke pa-
tients were limited to those who could walk more than
30m independently without a walking frame. All partic-
ipants performed basic physical examinations (height,
weight, electrocardiogram, blood pressure, blood test) be-
fore the experiment, and participants were paid partic-
ipation fee including transportation expenses. In addition,
the participants were instructed to give up the experiment
at any time according to the health condition of the ex-
periment day Proposed Gait monitoring system is con-
sists of insole foot Pressure sensor and accelerometer
which will be attached to foot as shoe insole for gather-
ing gait speed, foot pressure and other gait signals.
Gait Feature Vectors for Post-stroke Prediction using Wearable Sensor 59
Normal elderly (n=220) Elderly Stroke Patients (n=63)
Gender (Years)M: 98 (44.5%) F: 122 (55.5%)
M: 42 (66.7%) F: 21 (33.3%)
Age (Mean, std.) 68.45 ± 4.22 73.26 ± 6.18
Height/Weight (cm) 157.13/59.76 157.47/60.19
Systolic /Diastolic Blood pressure (mmHg) 134.22/79.33 134.78/79.55
Table 1. Demographic characteristics of recruited elderly normal and stroke patients
2.3. Data acquisition system
The insole sensor was the Dynamic pressure mapping
system, Dynafoot 2 (TechnoConcept, Pitaugier, MANE,
France). There are 58 pressure (resistance) sensors and
accelerometers on the bottom of the insoles. The thick-
ness of the insole is 2mm and the size of the resistance
sensor is 9 * 9mm and the measurement range is 2000g.
The accelerometer was twin-axial and the measuring
range was +/- 6g. The sampling rate was 100Hz. And
the data transfer module is 49 * 38 * 19mm which is
mounted on the shoe.
In the recording mode, there is no limit to the meas-
uring distance and it is possible to measure up to 3.5
hours.
2.4. Data analysis
Experimental data was measured using Dynafoot 2
and extracted using Dynafoot2_V2.2.14.0 software. The
measured features were the pressure per cell, the center
of pressure [CoP; CoP_Left_x axis (medial, lateral),
CoP_Left_y axis (anterior, posterior), CoP_Right_ x ax-
is (medial, lateral), CoP_Right_ y axis (anterior, poste-
rior)], the acceleration (Acc._left foot, acc._right foot,),
and the ground reaction force (GRF; GFR._left foot,
GFR._ right foot,).
Gait data were analyzed using IBM SPSS Modeler
18.0. After data preprocessing (outlier removal), patient
data were amplified to adjust the data distribution ratio of
stroke patients and normal persons. Then statistical analy-
sis method was paired t-test at a confidence level of 95%.
3. Results
3.1. Static Standing Position
3.1.1. Plantar Center of Pressure (CoP)
CoP displacement was measured in both feet of a
normal elderly person and a stroke patient in a static
standing state, and was analyzed into the medial, later-
al, anterior, and posterior regions (confidence level of
95%) as shown Fig. 3.
3.2. Gait/Movement
3.2.1. Gait task duration
After standing in static condition, participants per-
formed 20m gaiting test along the guide tape line. Fig.
4 shows the gaiting time of the normal group and the
patient group. The normal group reached the end point
with 18.98 ± 4.672s, while the patient group reached
the end point with 43.75 ± 29.830s. There was a sig-
nificant difference in arrival time between two groups
(p-value <.01).
3.2.2. Gait accelerations
The maximum and average accelerations of the feet
were measured from the accelerometer embedded in the
insole, and paired t-test was performed. In the Fig. 5,
the average acceleration of the normal group was meas-
ured as 17.18 ± 10.563m/s² and 19.44 ± 19.365m/s²,
left foot and right foot respectively, and the average ac-
celeration of the patient group was measured as 12.20
± 1.167m/s² and 12.67 ± 1.519m/s². It was clear that
60 Seunghee Hong․Damee Kim․Hongkyu Park․Young Seo․Iqram Hussain․Se Jin Park
(a) (b)
(c) (d)
Fig. 3. CoP displacement from plantar center of normal group and stroke patients group: (a) medial and lateral CoP displacement of left plantar, (b) anterior and posterior CoP displacement of left plantar, (c) medial and lateral CoP displacement of right plantar, (d) anterior and posterior CoP displacement of right plantar (** p-value <.01)
Fig. 4. Gait duration from the starting point to the end point
(** p-value <.01).
(a) (b)
Fig. 5. Acceleration of the normal group and the stroke patient group during gating: (a) average acceleration, (b) maximum acceleration (** p-value <.01).
Gait Feature Vectors for Post-stroke Prediction using Wearable Sensor 61
the average acceleration of the normal group was sig-
nificantly higher than the average acceleration of the pa-
tient group. The maximum acceleration of the normal
group was 75.24 ± 9.758m/s² and 73.39 ± 11.700m/s²,
left foot and right foot respectively. The maximum ac-
celeration of the normal group was 66.96 ± 11.597m/s²
and 69.28 ± 11.563m/s², respectively. Both the aver-
age acceleration and the maximum acceleration were
significantly higher in the normal group (p-value
<.01).
4. Discussion
The CoP displacement in the left foot of the stroke
patients was significantly larger than that of the normal
elderly. The anterior and posterior CoP displacement
showed a significant increase in stroke patients also.
Especially the anterior movement was very prominent.
It was also found that in the stroke patients, the CoP
of the left foot was shifting in the anterior-medial
direction. On the other hand, in CoP displacement of
the right foot, the shift value in the anterior-posterior
direction was larger in patients with stroke. These re-
sults suggest that stroke patients have difficulty in con-
trolling the balance because they cannot tolerate weight
bearing on the plantar part. Haart et al. (2004) reported
that stroke patients had weight gain in the forefoot due
to an ankle muscle imbalance and that the balance was
shaken to the outside of the foot. It obvious to main-
tain balance in the anterior medial side to control the
unbalance in the stroke patients. Therefore, when the
patient was standing in a static state, it was confirmed
that the stroke patient maintained an anterolateral bal-
ance and that the CoP of the plantar in the ante-
roposterior direction were higher.
The CoP from normal and patient groups were also
plotted and the normal range of pressure center values
was specified. The range of the normal that does not
include outliers was indicated by box in the scatter plot
as shown in the Fig 6. In the left foot, patient data of
the anterior-lateral side and normal group data of the
posterior-lateral side were distributed. On the right
foot, the patient data of the posterior side were dis-
tributed and the data of the normal side were scattered
on the mediolateral part. As a result, CoP values out-
side the normal range were also observed in the normal
group. This suggests that physical degeneration due to
aging has generated an abnormal value even though it
is a normal elderly person.
Fig. 6. CoP distribution of normal elderly people and stroke patient (left and right foot, respectively)
62 Seunghee Hong․Damee Kim․Hongkyu Park․Young Seo․Iqram Hussain․Se Jin Park
In addition, gait time and acceleration were obtained
from the gait test. The results showed that the gait time
of the normal group was significantly faster and the ac-
celeration value was higher in the normal group. From
these results, it was clear that walking speed was a very
clear feature in predicting stroke. As shown in Fig. 7,
it was confirmed that the acceleration of patients who
have plotted the left and right maximum acceleration
values on a three-dimensional graph was clearly dis-
tinguished from the range of normal persons.
Fig. 7. CoP placement limit box of normal elderly people (left and right foot, respectively)
However, since the shape of the foot is very different
according to the user, and the state of the surface of the
ground is different according to the environment in which
the user lives and the user, it is difficult to detect the ab-
normal data only through the simple statistics. Therefore,
in the future, the conditions for the experimental environ-
ment will be expanded, bio - signal data will be collected,
and reliability will be improved by using algorithms using
machine learning and deep learning.
5. Conclusions
Balance in standing posture and gait in patients with
stroke are important factors in evaluating functional in-
dependence (Turnbull, Charteris, & Wall, 1995). And
those have been analyzed in various methodologies.
Balancing in standing has been evaluated using the
COP, the COP-COG, and the Foot pressure. Hence, the
evaluation tools of the gait are much more diversified.
The common methods for hemiplegic are the velocity,
the cadence, the step length, the single time ratio, and
the stance phase symmetry ratio. Among these, the ve-
locity is easy to measure and corresponds to the clin-
ical condition of the patient (Wall & Turnbull, 1986;
Roth et al., 1997). Also, it was observed that hemi-
plegic patients were closely related to the cadence, the
velocity, the muscle strength, the Barthel index score
and the gait pattern (Dettman, Linder, & Sepic, 1987).
On the other hand, the most prominent gait patterns for
stroke patients presented the low gait velocity, the
short stance phase, and the difference in step length be-
tween the paralyzed side and non-paralyzed side of the
body (Mauritz, 2002). As such, it has been developed
into a multi-faceted evaluation method such as the
COP, COG and foot pressure method when standing
and the velocity, the cadence, the step length, the sin-
gle time ratio, and the stance phase symmetry ratio
method when walking. For real-time health monitoring,
the temporal and spatial variables during daily time
must be measured accurately. In addition, there should
be no limitation in the measurement environment in or-
der to determine the difficulty of maintaining the bal-
ance of the body and the abnormality of walking.
However, foot pressure varies considerably depending
on the road surface, and gyro sensors using magnetic
sensors are affected by such values in environments
with many electronic devices. Therefore, sensors and
measurement variables for daily monitoring should not
be influenced by the environment, and the use of opti-
mal parameters should be a priority.
The purpose of this study was to extract the optimal
variables to detect abnormalities of stationary posture
and walking during daily life, and to find the difference
Gait Feature Vectors for Post-stroke Prediction using Wearable Sensor 63
between stroke patients and the normal elderly. However,
the stroke patients who were in-rolled in this study were
patients within three months of onset and were unable to
collect patient data at the time of onset. However, we
will develop machine learning and deep learning algo-
rithms and embed them in our stroke monitoring system.
After that, we will conduct follow-up studies on older
people to monitor stroke incidence and will also collect
additional data at the time of onset. Once the system has
been developed and validated, it is expected to reduce
the sequelae and mortality caused by delays in treatment
time after stroke.
Acknowledgments
This work was supported by the National Research
Council of Science & Technology (NST) grant by the
Korea government (MSIP) (No. CRC-15-05-ETRI).
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원고 수: 2019.06.19
수정 수: 2019.08.21
게재확정: 2019.08.21
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