Journal Pre-proofs

Effects of cane use on the kinematic and kinetic of lower-extremity joints in

inexperienced users

Yanyu Zhang, Chunjing Tao, Xiaohui Zhang, Jiangzhen Guo, Yubo Fan

PII: S0021-9290(22)00467-5
DOI: https://doi.org/10.1016/j.jbiomech.2022.111426
Reference: BM 111426

To appear in: Journal of Biomechanics

Received Date: 6 September 2022

Revised Date: 23 November 2022
Accepted Date: 29 December 2022

Please cite this article as: Y. Zhang, C. Tao, X. Zhang, J. Guo, Y. Fan, Effects of cane use on the kinematic and
kinetic of lower-extremity joints in inexperienced users, Journal of Biomechanics (2022), doi: https://doi.org/
10.1016/j.jbiomech.2022.111426

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 1 Original Research

2 Effects of cane use on the kinematic and kinetic of lower-extremity

3 joints in inexperienced users

4 Yanyu Zhang, Chunjing Tao*,1, Xiaohui Zhang, Jiangzhen Guo, Yubo Fan*,2

5 Beijing Advanced innovation center for biomedical engineering, school of Engineering Medicine, School of Biological Sciences and Medical Engineering,

6 Beihang University, Beijing 100083, P. R. China

7 Abstract

8 The cane is commonly prescribed for the elderly to maintain balance and enhance independent mobility. However, improper use of

9 cane can increase the risk of falling. Understanding the characteristics of cane gait is critical for better establishing proper cane usage

10 norms. The paper aimed to investigate effects of cane use on kinematics and kinetics of lower extremities in the elderly and the young

11 to guide the development of adaptive cane gait. Twenty participants (10 elder and 10 young) were recruited and walked at a self-

12 comfortable speed or with a cane in a two-point gait. The spatiotemporal gait parameters, hip/knee/ankle joint angles and ground

13 reaction force (GRF) were statistically analyzed using MANOVAs to assess the effects of age and cane. Using the cane significantly

14 decreased step length, cadence and speed and increased step time in both age groups. Age and cane had significant effects on ankle

15 plantarflexion angle in initial swing phase (APA-ISw). In cane gait, the peaks of vertical GRF(V-GRF) and anterior-posterior GRF (AP-

16 GRF) in bilateral lower extremities significantly decreased, and the troughs of right V-GRF significantly increased for both groups. These

17 results suggest that using a cane does interfere with the natural gait of the user and insufficient ankle plantarflexion in initial swing

18 phase (ISw) and reduced AP-GRF may be two key risk factors contributing to cane gait instability. Therefore, the users should consider

19 actively increasing ankle plantarflexion in ISw to avoid deteriorating gait performance due to over-reliance on the cane.

20 KEYWORDS: Cane; Age; Adaptive Gait; Joint angle; Ground reaction force

21 1. Introduction

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22 With the increasing aging of the world population, the demand for mobility aids has increased rapidly (Cieza et

23 al., 2020). Age-related degenerative diseases of physical function can severely impair the balance and motor control

24 ability in the elderly, and even lead to fall that is one of most major risk factors of hospitalization and injury for the

25 elderly (Van Hook et al., 2003; Luz et al., 2017). Worryingly, some studies have revealed that improper use of

26 mobility aids can also increase of fall risks (Salminen et al., 2009; Deandrea et al., 2010; Edelstein, 2013). The cane,

27 the most popular assistive device, is commonly prescribed to maintain balance and enhance mobility independence in

28 the elderly (Bateni and Maki, 2005; Cruz et al., 2020; Iolascon et al., 2021). However, several investigations

29 demonstrate a large proportion of the elderly with assisted walking needs are unwilling to accept a mobility aid or end

30 up disusing their cane/walker due to insufficient awareness of self-needs, lack of understanding of mobility aids

31 necessity and social stigma of mobility aids, etc. (Härdi et al., 2014; Bertrand et al., 2017) Although the importance of

32 promoting the knowledge and education of assisted walking among the elderly has been emphasized many times,

33 there are a lack of specific guidance and suggestions on how to use cane properly. In this paper, effects of cane on the

34 kinematics and kinetics of the lower extremity joints in the elderly and the young are studied to distinguish the age-

35 related gait changes and to encourage the development of cane gait adaptability.

36 Gait adaptability refers to the ability to change walking patterns to meet task objectives and environmental

37 demands. When using the cane, the user often fails to maintain an appropriate reciprocal gait pattern and have

38 inappropriate walking posture (forward or lateral lean) (Balasubramanian et al.,2014; Liu H. H. et al.,2011). Bateni et

39 al. (2004) studied a possible lateral stepping compensatory mechanism using a single-tip cane or a standing pick-up

40 walker, and found that 60% and 11% of stepping collisions reactions occurred between the swing-foot and mobility or

41 cane, respectively. Guild et. al. (2012) studied force, impulse, standing time, swinging time, cadence and velocity in

42 healthy young people with or without one-legged, three-legged and four-legged canes in the right hand. The results

43 showed that the subjects' gait speed and cadence decreased synchronously, and that the lower-extremity force on the

2
44 cane side increased. Using a cane creates a dependently mechanical environment for users, which may change the

45 movement pattern of lower extremity joints in the elderly under the long-term accumulation effects, making it

46 difficult for the elderly to exert maximum advantage benefits of a cane with the minimum efforts (Youdas et al., 2005;

47 Sehgal et al., 2021). In addition, a great majority of the elderly choose a cane recommended by their relatives and

48 friends, and rarely get professional guidance on how to properly use, even in medical institutions, physicians are

49 more concerned with adjusting an optimum cane height to reduce stress injuries in cane ipsilateral upper-extremity (

50 Jayakaran et al., 2014; Li Z Y and Chou C, 2014).

51 At present, most studies compared the effects of different mobility aids on gait spatiotemporal parameters,

52 muscle activation modes, and sagittal plane joint kinetics in patients with different diseases (stroke, hip arthritis,

53 knee arthritis, etc.), and the results showed that the cane can change gait performance to varying degrees (Hardi et

54 al., 2014; Kang et al., 2021; Sudiyono et al., 2020). Omana et al. (2021) firstly investigated the effects of different

55 walking path configurations and cognitive load on walking speed and stride time variability in young and old adults.

56 Based on this, this study comprehensively analyzed effects of cane on gait performance from spatiotemporal

57 parameters, hip/knee/ankle joint angles and ground reaction force (GRF) at different anatomical planes. This study

58 is based on the following two hypotheses: 1. using a cane will limit the range of motion of the user's lower extremity

59 joints in left and right sides; 2. Using a cane will increase the vertical ground reaction force (V-GRF) and reduce the

60 anterior-posterior GRF (AP-GRF) and the medial-lateral GRF (ML-GRF) of the cane ipsilateral lower extremity,

61 which may contribute to cane gait instability.

62 2. Methods

63 2.1. Participants

64 This study was approved by the Science and Ethics Committee of School of Biological Science and Medical

65 Engineering in Beihang University, China. Twenty participants were recruited from the National Research Center for

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66 Rehabilitation Technical Aids (NRRA) and Beihang University, China. They were divided into two groups, one was the

67 young (n=10, male: female=6:4, age = 24.62±0.74 years; body mass index BMI = 19.62 ± 2.92 kg/m2) and the other

68 was the elderly (n=10, male: female=7:3, age = 63.56±1.12 years; BMI = 24.52 ± 1.12 kg/m2). All elderly participants

69 were able to walk normally without mobility aids. We excluded participants with musculoskeletal system injury caused

70 by trauma, surgery, chronic disease within one year. The participants were clearly informed of the process of the

71 experiment and provided their written informed consent. The emergency treatment plan was guided by a professional

72 rehabilitation physician coming from NRRA.

73 2.2. Procedures

74 This experiment was carried out on a horizontal walkway involving four intersectional scenarios, 1) the young

75 walking in nature gait, 2) the young walking using a cane, 3) the elderly walking in nature gait, and 4) the elderly

76 walking using a cane. An adjustable height aluminum cane was used. Participants held the cane in their dominant right

77 hand, and the optimal height of cane is level with the styloid process of the wrist in the standard anatomical standing

78 position to achieves the elbow flexion of 20° to 30°. The participants' body parameters, including height, weight, leg

79 length, knee width, ankle width, elbow width, wrist width and palm thickness were measured, and 39 passive optical

80 markers were pasted onto the corresponding anatomical locations of the subjects' body according to the Plug-in Gait

81 full-body model. The walking movement of the participants were recorded by a Vicon 3D motion capture system

82 (Oxford metrics, UK) and an AMTI force plate system (AMTI, USA). The Vicon contains 12 cameras with a sampling

83 frequency of 100 Hz for motion capture, and the AMTI contains two force plates with a sampling frequency of 1000 Hz

84 (Fig. 1). The Vicon Nexus software and Vicon Polygon software were used to process and display the test data.

85 In the pre-experiment, the participants were trained to ignore the tension in an experimental environment, and

86 maintain their habitual gait at a comfortable speed, then they were instructed to use the cane in a two-point gait mode:

87 the first step was to move the cane and contralateral extremity (left) forward simultaneously, and the second step was

4
 88 to move the ipsilateral extremity (right) forward (the following is indicated by left/ right lower extremity). Meanwhile,

89 they were instructed not to press the cane against the AMTI force plates and to step on different force plates with their

90 feet to generate effective mechanical results. The experiment was repeated until 6 valid results were obtained for each

91 scenario.

92 2.3. Statistics

93 The gait cycle based on the trajectory of the left heel marker was normalized by a custom MALAB R2019b program.

94 The lower extremity Plug-in Gait model was developed by the Visual3D software (C-Motion Inc., USA). The kinematic

95 parameters were described in a complete gait cycle, and the kinetic parameters were described only in the stance phase.

96 Statistical analysis was performed using IBM SPSS Statistics 25.0 with the values expressed as the means ±

97 standard deviation (SD). Two-way “age” and “cane” MANOVAs were performed for the spatiotemporal gait parameters,

98 hip/knee/ankle joint angles and the characteristics of GRF (including V-GRF, AP-GRF and ML-APL), and one-way

99 “left/right” ANOVA was performed for symmetry within the group. The significance level was set at P <0.05 and the

100 effect size (ES) was shown as η2.

101 3. Results

102 3.1. Spatiotemporal gait parameters

103 The spatiotemporal gait parameters were presented in Table 1. Age had a significant effect on speed (P<0.001),

104 left/right double support phase (P<0.01), stride length (P<0.001) and left/right step length (P<0.001), and the elderly

105 experienced lower speed, stride length, and step length, and more double support phase. Moreover, Cane had a more

106 significant effect on all spatiotemporal gait parameters. The elderly speed decreased by 18.6% and the young speed

107 decreased by 22.0% respectively compared with natural gait (P<0.001, ES η2=0.454). For left and right symmetry, only

108 the right step length (0.54±0.04m, P<0.05, ES η2=0.194) of the elderly shortened in cane gait.

109 3.2. Hip, knee and ankle joint angles

5
110 The joint angle-time curves of the left/right hip, knee, and ankle joints in the sagittal plane during a gait cycle were

111 compared in Fig.2. The vertical axis (±) represents flexion and extension of the hip/knee joint, and dorsiflexion and

112 plantarflexion of the ankle joint. The joint angle characteristics of hip/knee/ankle were described in Table 2.

113 We divided the gait cycle according to the trajectory of the left heel marker. In Pre swing phase (PSw), hip joint

114 extended to maximum hip extension angle (Max-HEA) and in terminal swing phase (TSw), it flexed to the maximum

115 hip flexion angle (Max-HFA). Only the left hip range of motion (RoM) were affected significantly by age (P<0.01, ES η2

116 =0.208) and cane (P<0.01, ES η2 =0.217). In mid stance phase (MSt), knee joint has a flexion peak angle (MSt-KFA)

117 and in mid swing phase (MSw), it flexed to a maximum knee flexion angle (MAX-KFA). Age and cane significantly

118 affected the knee RoM and right Max-KFA, particularly for right knee RoM, the age significance is P<0.001 (ES η2

119 =0.427) and the cane significance is P=0.001 (ES η2 =0.331). In swing phase, the great impact on ankle joint movement

120 came from age, with the ankle RoM, ankle plantarflexion angle in ISw (ISw-APA) and ankle dorsiflexion angle in MSw

121 (MSw-ADA) significantly decreasing in the elderly (P<0.001, ES η2 =0.4~0.7). The left and right ISw-APAs also were

122 also significantly affected by cane (P<0.05, ES η2 =0.1~0.2). There were no significant differences in the ankle

123 dorsiflexion angle in TSw (TSw-ADA) for the age and cane groups.

124 3.3. Ground Reaction Force(GRF)

125 The Schematic of left lower extremity GRF was shown in Fig.3 (A) and GRF-stance phase curves were shown in

126 Fig.3 (B) (C) (D), and the force characteristics of the GRF were shown in Table 3.

127 In sagittal plane, the V-GRF on left and right sides were both M-shaped, with two peaks (Fmax-1 and Fmax-2 ) and a

128 trough (Fmin) in Fig. 2 (B). For age factor, only left lower extremity Fmin (L-Fmin) and right lower extremity Fmax-2 (R-

129 Fmax-2) were significantly affected. For cane factor, two peaks of left/right V-GRF had greater significance (P<0.001,

130 ES η2 =0.5~0.7), and R-Fmin significantly increased for both groups (P<0.001, ES η2 =0.652). In addition, there were

131 asymmetry between left and right V-GRF only in cane gait for the young and the elderly, and the right V-GRF were

6
132 higher (P<0.05, ES η2 =0.2~0.8). It was worth noting that L-Fmax-2 and R-Fmax-2 had an offset tendency from PSw to

133 terminal stance phase (TSt) (~60% stance phase), and the offset values were 0.87±0.06 N/kg and 0.95 ±0.03 N/kg

134 respectively.

135 In coronal plane, the AP-GRF provided driving force and braking force for walking. In the first half of stance

136 phase, AP-GRF was opposite to the walking direction to provide braking force and increased heel landing stability. In

137 the last half of stance phase, AP-GRF was always consistent with walking direction to provide driving force and

138 prevent toe slip. As showed in Fig. 2 (C), only R-DFmax was affected by age, and a lower change in the elderly

139 (P<0.05, ES η2 =0.218). L-BFmax (P<0.01, ES η2 =0.322), L-DFmax (P<0.001, ES η2 =0.530), R-BFmax (P<0.05, ES η2

140 =0.246) and L-DFmax (P<0.05, ES η2 =0.244) in cane gait decreased significantly.

141 In transverse plane, the ML-GRF maintained stability of feet. In initial contact phase (IC), the lateral ML-GRF (-)

142 were generated to expand step width, and subsequently the medial ML-GRF (+) to ensure the full foot landing stably

143 and prevent sideslip. As showed in Fig. 2 (D), age had a significant effect on L-LF1 (P<0.01, ES η2 =0.319), and cane

144 had a significant effect on R-LF1 (P<0.05, ES η2 =0.182) and R-MF2 (P<0.05, ES η2 =0.191).

145 4. Discussion

146 In this work, the effects of age and cane on spatiotemporal gait parameters are significant, especially speed, which

147 is one of most important parameters for assessing walking ability (Kressig et al., 2006; Studenski et al., 2011;

148 Hollman et al., 2011). Using a cane did affect walking speed, and the effect size was greater for the young than the

Stride length
149 elderly in Table 1. Speed = Gait cycle or Speed = cadence × step length. In natural gait, the step length and stride

150 length in the elderly decreased significantly, and the gait cycle increased slightly, so the walking speed in the elderly

151 was significantly lower than that of the young. In cane gait, the step time increased significantly and the cadence

152 decreased significantly in two groups. In the young, the step length and stride length reduced more under the cane gait,

153 so the walking speed decreases more. Using the cane mobilized the mutual coordination ability of the upper and lower

7
154 extremities. On temporal domain, the step time and gait cycle increased, which may be related to the coordination

155 control of the cane consuming the user's attention (Suzuki et al. 2019; Hunter et al.2019; Omana et al. 2021); on

156 spatial domain, the forward distance of the cane was limited by the forward swing of the right upper extremity, and the

157 left lower extremity needed to synchronously adapt to the landing position of the cane, as a result, the step length and

158 stride length decreased. In addition, the gait adaptability of the elderly is weakened, and using the cane leaded to step

159 length asymmetry of bilateral lower extremities, that is the right step length shorted.

160 Changes on spatiotemporal gait parameters relate to lower-extremity joint angles and GRF. In gait cycle, the hip,

161 knee, and ankle joints coordinate with each other to complete walking forward. When joint movement is blocked, there

162 may be a risk of falling ( Kobayashi et al., 2014). The synchronous movement between left extremity and the cane

163 significantly limited the RoM of left hip, left knee and left ankle. Although there was no significant difference, the Max-

164 HFA in the elderly decreased in TSw. This result is noteworthy and may vary significantly in senile elderly population.

165 The cane imposed significant restrictions on the right knee RoM and right Max-KFA, which may account for the

166 shortened right step length.

167 Age has a greater effect on the movement of ankle joint, especially in ISw and MSw. For the young, ankle joint

168 pushed toe off the ground at a larger ISw-APA (>10°), and then quickly dorsiflexed to MSw-ADA (2°-3°), finally the

169 ankle joint dorsiflexed again to TSw-ADA (7°-8°) to make the swing foot land. But for the elderly, the movement mode

170 of ankle joint in swing phase changed. The ISw-APA decreasing (<5°) may form a mopping gait and recurring foot

171 plantarflexion from MSw to TSw may lead to toe first contacting the ground, which require the elderly put more effort

172 into keeping feet clearance (Begg and Sparrow, 2006; Nagano et al., 2011).

173 There was no significant difference in joint angle symmetry between the left and right lower extremities in all

174 groups (p>0.05), but the statistical results showed that age had different significant effects on the left and right joint

175 angles. Age had significant effects on left hip RoM (P<0.01, ES η2 =0.208) and right Max-KFA (P<0.01, ES η2 =0.296),

8
176 but not on right hip RoM (P=0.067, ES η2 =0.108) and left Max-KFA (P=0.983, ES η2 =0.0), which is possibly related

177 to dominant walking foot and coordination between hip joint and knee joint (Nagano et al., 2011; Yoshida et al.,

178 2014). In the study, all participants are left dominant walking foot, with the left foot stepping first. For the elderly, the

179 posture control and proprioceptive ability are weakened, showing different control over the left and right lower

180 extremity. One possible explanation is that the elderly may compensate for the reduction of left hip RoM by maintaining

181 the left Max-KFA (~ 68°), but relatively week control over the non-dominant right lower extremity gave rise to right

182 Max-KFA reducing (~64°).

183 The V-GRF is considered as a representative measure to discriminate normal from pathological gait patterns

184 (Trentadue et al., 2021). In nature gait, the higher L-Fmin of the elder implied that unilateral leg supporting was more

185 unstable in MSt, and the lower R-Fmax-2 of the elderly demonstrated the insufficient push off forces of their non-

186 dominant foot toe. In cane gait, the two V-GRF peak forces of left lower extremity decreasing were due to assistive

187 support of the cane, but the R-Fmin significantly increasing represented the right lower extremity bore more weight in

188 MSt, which may cause potential mechanical fatigue. Moreover, the asymmetry of V-GRF in cane gait was a risk factor

189 to result in deterioration of gait symmetry, which needs to be further explored in long-distance consecutive walking.

190 Interestingly, two findings are noticed: 1) in cane gait, the second peak of the elderly group had a shift from the

191 PSw to TSt phase. The trend of deviation indicated that the elderly focused more on their stability in the TSt phase to

192 support single foot standing. Unfortunately, the V-GRF force reducing in PSw and ankle joint plantarflexion insufficient

193 in ISw may make the elderly difficult to complete foot clearance and form mopping gait. 2) AP-GRF and ML-GRF are

194 two easily unappreciated critical kinetic parameters that should be investigated farther. AP-GRF is the key to enhance

195 gait propulsion, and ML-GRF is greatly correlated with gait lateral stability (Deffeyes and Peters, 2021). The walking

196 propulsive force and braking force decreased significantly after using the cane, with insufficient driving, easy to trip,

197 and lack of braking, easy to slip. The ML-GRF varied greatly between individuals, several elderly participants performed

9
198 sensitive changes in ML-GRF, but the average ML-GRF curves obscured these individuation differences, which may be

199 the potential mechanical markers to identify the elderly prone to fall.

200 For the two hypotheses proposed in this study, the results showed that using the cane limited the RoM of the

201 bilateral knee joints, increased the right V-GRF trough value (R-Fmin) and decreased bilateral AP-GRF. When the elderly

202 feel difficult to walk, choosing a suitable cane and using it properly can enhance walking confidence and maintain gait

203 performance. Therefore, we recommend that the inexperienced users, especially geriatric novice users, should carry

204 out cane gait adaptation training before bringing a cane into their daily life. The training should include 1) equidistantly

205 marking the step length of cane ipsilateral lower extremity to repeatedly train bilateral gait symmetry; 2) initiatively

206 controlling the movement of ankle joint to stimulate tibialis anterior muscle groups and maintain foot flexibility in ISw.

207 The user should increase the ankle joint plantarflexion movement to push the toe off the ground in the ISw, stabilize

208 ankle dorsiflexion in the MSw and land at a maximum ankle dorsiflexion angle in the TSw, so as to avoid recurring foot

209 plantarflexion and toe first contacting the ground.

210 There are some limitations. First, we failed to analyze the characteristics of continuous gait due to limited

211 experimental space, fatigue and posture instability might arise frequently in long-distance walking using a cane.

212 Second, the walking environment was on a smooth wooden floor in the study, however, there were a variety of ground

213 conditions in daily life, such as uphill, downhill, slope, cobblestone road, and smooth pavement, etc. In order to make

214 better use of a cane, the multi-types ground environment need to be further studied. Third, the study did not fully

215 consider the gait performance of different groups using the cane. The elderly often suffer from a variety of chronic

216 diseases, including low back pain, arthritis, diabetes and cardiovascular disease, etc., all of which lead to varying

217 degrees of gait impairment. Typical abnormal gait, such as hemiplegic gait, festinating gait, scissors gait and so on, are

218 more challenging to the adaptability of cane gait. This study focused on investigating effects of age on developing

219 adaptive cane gait, providing a baseline for gait changes into different elderly groups using the cane and contributing

10
220 to distinguish differences between age and pathological features in cane gait. Future studies should evaluate how to

221 select appropriate walkers for different groups and develop corresponding using guidelines.

222 5. Conclusion

223 The present findings indicated that using the cane resulted in speed declining in the young and the elderly due to

224 step time increasing, step length decreasing and cadence decreasing. In the elderly, using the cane also caused right

225 step length lower than the left step length and limited maximum knee flexion angle in MSw. More importantly, age

226 changed the movement pattern of the ankle in the swing phase, and cane-using seriously affected the ankle

227 plantarflexion angle in ISw. For two age groups, using the cane increased the right V-GRF trough value, reduced the

228 right V-GRF second peak and lowered the AP-GRF. Based on these findings, an adaptive cane gait training program

229 was proposed to help first-time cane users use the cane more safely.

230 Funding

231 This work was supported by the National Key R&D Program of China (2020YFC2005900) and the National

232 Natural Science Foundation of China (12072081).

233 CRediT authorship contribution statement

234 Yanyu Zhang: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing–original

235 draft, Visualization. Chunjing Tao: Conceptualization, Writing-Review & Editing, Supervision, Project

236 administration, Funding acquisition. Xiaohui Zhang: Methodology, Data curation. Jiangzhen Guo: Writing-

237 Review & Editing, Supervision. Yubo Fan: Conceptualization, Writing-Review & Editing, Supervision, Project

238 administration.

239 Declaration of Competing Interest

240 The authors declare that they have no known competing financial interests or personal relationships that could

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241 have appeared to influence the work reported in this paper.

242 Acknowledgments

243 We thank all our participants for volunteering in this research. The project was carried out with the support of the

244 the National Key R&D Program of China (2020YFC2005900) and the National Natural Science Foundation of China

245 (120720810).

246 References

247 Bateni, H., Heung, E., Zettel, J., McLlroy, W. E., Maki, B. E., 2004. Can use of walkers or canes impede lateral compensatory stepping movements?.

248 Gait & Posture. 20 (1)，74-83.

249 Bateni, H., Maki, B. E., 2005. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch. Phys. Med. Rehabil.

250 86 (1), 134-145.

251 Balasubramanian, C. K., Clark, D. J., Fox, E. J., 2014. Walking adaptability after a stroke and its assessment in clinical settings. Stroke. Res. Treat.

252 2014:591013.

253 Begg, R. K., Sparrow, W. A., 2006. Ageing effects on knee and ankle joint angles at key events and phases of the gait cycle. J. Med. Eng. Technol. 30

254 (6), 382-389.

255 Bertrand, K., Raymond, M. H., Miller, W. C. , Martin Ginis, K. A. and Demers, L., 2017. Walking Aids for Enabling Activity and Participation: A

256 Systematic Review. Am J Phys Med Rehabil. 96 (12), 894-903.

257 Cieza, A., Causey, K., Kamenov, K., Hanson, S.W., Chatterji, S., Vos, T., 2020. Global estimates of the need for rehabilitation based on the Global

258 Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study. The Lancet. 396 (10267), 2006-2017.

259 Cruz, A. O., Santana S. M. M., Costa C. M., Gomes da Costa L. V., Ferraz D. D., 2020. Prevalence of falls in frail elderly users of ambulatory assistive

260 devices: a comparative study. Disabil. Rehabil. Assist. Technol. 15 (5), 510-514.

261 Deandrea, S., Lucenteforte, E., Bravi, F., Foschi, R., La Vecchia, C., Negri, E., 2010. Risk factors for falls in community-dwelling older people: a

262 systematic review and meta-analysis. Epidemiology. 21, 658-668.

263 Deffeyes, J. E., Peters D. M., 2021. Time-integrated propulsive and braking impulses do not depend on walking speed. Gait Posture. 88, 258-263.

264 Edelstein, J. E., 2013. Assistive devices for ambulation. Phys. Med. Rehabil. Clin. N. Am. 24 (2), 291-303.

265 Sehgal, M., Jacobs, J., Biggs, W. S.,2021. Mobility assistive device use in older adults[J]. Am. Fam. Physician.103(12): 737-744.

266 Iolascon, G., Michini, C., Sentinella, R. K., Milena, A., Moretti, A., 2021. The role of assistive devices in frail elderly people with fragility fractures: a

267 narrative review. Int. J. Bone. Frag. 1 (2), 53-58.

268 Hardi, I., Bridenbaugh, S. A. , Gschwind, Y. J. , and Kressig, R. W. , 2014. The effect of three different types of walking aids on spatio-temporal gait

269 parameters in community-dwelling older adults. Aging. Clin. Exp. Res. 26 (2),221-228.

270 Hollman, J. H., McDade, E. M., Petersen, R. C., 2011. Normative spatiotemporal gait parameters in older adults. Gait & Posture. 34 (1), 111-118.

271 Hunter, S. W., Divine, A., Omana, H., et al.,2019. Effect of learning to use a mobility aid on gait and cognitive demands in people with mild to

272 moderate Alzheimer’s disease: part I–cane. J. Alzheimers. Dis. 71: S105-S114.

273 Jayakaran, P., DeSouza L., Cossar J., Gilhooly K., 2014. Influence of a walking aid on temporal and spatial parameters of gait in healthy adults. PM

274 R. 6 (9), 796-801.

275 Guild, J. R., SDPT, Hao (Howe) Liu, MPT, et al., 2012. Comparison of gait while ambulating with three different types of canes with normal

276 subjects: a pilot study. Int. J. Therap. Rehab. Res. 1 (3), 1-9.

277 Kang, Y. S., Oh, . B., Cho, K. H.,2021. Walking Training with a Weight Support Feedback Cane Improves Lower Limb Muscle Activity and Gait

278 Ability in Patients with Chronic Stroke: A Randomized Controlled Trial. Med. Sci. Monit.27,e931565-1.

12
279 Kobayashi, Y., Hobara H., Matsushita S., Mochimaru M., 2014. Key joint kinematic characteristics of the gait of fallers identified by principal

280 component analysis. J. Biomech. 47 (10), 2424-2429.

281 Kressig, R. W., Beauchet O., European G. N. G., 2006. Guidelines for clinical applications of spatio-temporal gait analysis in older adults. Aging.

282 Clin. Exp. Res. 18 (2), 174-176.

283 Li Z. Y., Chou, C., 2014. The effect of cane length and step height on muscle strength and body balance of elderly people in a stairway environment.

284 J. Physiol. Anthropol.1:33-36.

285 Liu, H. H., Eaves, J., Wang, W., et al., 2011.Assessment of canes used by older adults in senior living communities. Arch. Gerontol. Geriatr. 52(3):

286 299-303.

287 Liu, H. H., McGee O. U., Wang W., Persson M., 2009. Comparison of gait characteristics between older rolling walker users and older potential

288 walker users. Arch. Gerontol. Geriatr. 48, 276-280.

289 Luz C, Bush T, Shen X. ,2017.Do canes or walkers make any difference? Nonuse and fall injuries. The Gerontologist, 57,211-218.

290 Nagano, H., Begg R. K., Sparrow W. A., Taylor S., 2011. Ageing and limb dominance effects on foot-ground clearance during treadmill and

291 overground walking. Clin. Biomech. 26, 962-968.

292 Nishizawa, A., Katsuhira J., Watanabe M., Fujii T., Yoshimoto T., Oka H., Matsudaira K., 2022. Relationship between the locomotive syndrome and

293 kinetic and kinematic parameters during static standing and level walking. Gait & Posture. 93, 146-152.

294 Omana, H., Madou,. E, Divine, A., et al. 2021. The Differential Effect of First‐Time Single‐Point Cane Use between Healthy Young and Older

295 Adults[J]. PM R.13(12): 1399-1409.

296 Salminen, A. L., Brandt A., Samuelsson K., Toytari O., Malmivaara A., 2009. Mobility devices to promote activity and participation: a systematic

297 review. J. Rehabil. Med. 41, 697-706.

298 Studenski, S., Perera S., Patel K., Rosano C., et al., 2011. Gait speed and survival in older adults. JAMA. 305, 50-58.

299 Suzuki, T., Ogahara K., Higashi T., Sugawara K., 2019. The Effect of Cane Use on Attentional Demands During Walking. J. Mot. Behav. 51, 19-24.

300 Trentadue, T. P., Queen R. M., Schmitt D., 2021. Fourier analysis of vertical ground reaction forces distinguishes gait patterns in hip, knee, and

301 ankle osteoarthritis. Osteoarthritis and Cartilage. 29, S188-S190.

302 Sudiyono, N., 2020. The effect of a tripod cane on the functional mobility of patients with knee osteoarthritis. Berkala Ilmiah Kedokteran Duta

303 Wacana.5(1): 29-33.

304 Van Hook, F. W., Demonbreun D., Weiss B. D., 2003. Ambulatory devices for chronic gait disorders in the elderly. Am. Fam. Physician. 67, 1717-

305 1724.

306 Yoshida, T., Ikemiyagi, F., Tanaka, T., Yamamoto, M., Suzuki M., 2014. The dominant foot affects the postural control mechanism: examination by

307 body tracking test. Acta. Otolaryngol. 134, 1146-1150.

308 Youdas, J. W., Kotajarvi, B. J., Padgett, D. J., Kaufman, K. R., 2005. Partial weight-bearing gait using conventional assistive devices. Arch. Phys.

309 Med. Rehabil. 86, 394-398.

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311 Table 1 Spatiotemporal gait parameters

Young Group Elderly Group P-value Effect size η2

Spatiotemporal Parameters
Natural Gait Cane Gait Natural Gait Cane Gait Age Cane Age Cane

Cadence (steps/min)### 109.99±5.73 91.96±9.49 103.95±9.25 89.34±10.14 0.152 0.000 0.053 0.443

Speed (m/s)***; ### 1.23±0.08 0.96±0.18 1.02±0.15 0.83±0.11 0.000 0.000 0.334 0.454

Gait cycle (s)### 1.09±0.06 1.32±0.13 1.17±0.15 1.36±0.17 0.154 0.000 0.053 0.397

Left single support phase (s)## 0.40±0.02 0.45±0.05 0.41±0.05 0.46±0.06 0.688 0.002 0.004 0.232

Right single support phase (s)## 0.40±0.02 0.46±0.05 0.40±0.05 0.46±0.07 0.744 0.001 0.003 0.260

Left double support phase (s)*; ### 0.29±0.03 0.39±0.08 0.35±0.05 0.42±0.06 0.013 0.000 0.151 0.396

Right double support phase (s)**; ### 0.28±0.04 0.38±0.08 0.36±0.05 0.44±0.07 0.002 0.000 0.234 0.367

Left step time (s)### 0.55±0.03 0.66±0.06 0.59±0.08 0.69±0.09 0.101 0.000 0.069 0.364

Right step time (s)### 0.54±0.03 0.67±0.08 0.59±0.08 0.68±0.08 0.179 0.000 0.047 0.388

Stride length (m)***; # 1.34±0.06 1.25±0.13 1.17±0.09 1.12±0.08 0.000 0.013 0.414 0.153

Left step length (m)***; # 0.68±0.04 0.63±0.06 0.60±0.04 0.59±0.05 0.000 0.044 0.347 0.103

Right step length (m)***; # 0.67±0.03 0.63±0.07 0.58±0.05 0.55±0.03§ 0.000 0.018 0.456 0.139

312 Age significance: * denoted P<0.05; ** denoted P<0.01; *** denoted P<0.001.

313 Cane significance: # denoted P<0.05; ## denoted P<0.01; ### denoted P<0.001.

314 Left/right significance: § denoted P=0.040 (Effect size η2 =0.194).

315

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316 Table 2 Characteristic angle of hip, knee and ankle joint

Young Group Elderly Group P-value Effect size η2

Joint angle (°)
Natural Gait Cane Gait Natural Cane Gait Age Cane Age Cane

L**;## 47.89±2.85 43.53±4.34 43.90±3.52

Gait 41.11±1.93 0.009 0.007 0.208
Age 0.217
Hip RoM
R 46.43±3.70 44.31±5.37 43.11±4.52 42.07±3.13 0.067 0.287 0.108 0.038

L -4.29±7.553 -2.60±8.68 -4.49±5.92 -1.96±5.29 0.518 0.358 0.014 0.028

Max-HEA
R -5.70±7.12 -4.68±7.78 -5.61±5.27 -4.16±6.09 0.893 0.587 0.001 0.010

L 43.60±8.01 41.28±7.92 39.41±6.14 37.50±4.95 0.058 0.648 0.115 0.007

Max-HFA
R 40.73±8.31 39.63±8.21 39.14±5.99 37.91±5.25 0.353 0.875 0.029 0.001

L*;# 64.16±5.19 59.01±6.11 56.95±7.60 53.01±7.56 0.040 0.037 0.138 0.142

Knee RoM
R***;### 65.88±4.78 56.70±5.07 55.00±6.73 47.59±6.42 0.000 0.001 0.427 0.331

L 18.43±9.50 17.86±9.39 22.24±5.05 22.95±4.29 0.613 0.637 0.009 0.008

Mst-KFA
R 21.42±10.21 18.44±11.46 20.30±4.14 19.66±4.41 0.825 0.991 0.002 0.000

L 69.05±10.63 65.15±11.45 68.17±8.12 63.91±8.81 0.983 0.124 0.000 0.080

Max-KFA
R**;# 72.81±9.02 65.27±10.10 63.98±5.96 57.56±6.37 0.002 0.033 0.296 0.147

L**;# 30.31±6.26 24.33±5.37 23.72±4.81 19.83±4.15 0.010 0.030 0.228 0.168

Ankle RoM
R*** 31.41±4.97 28.69±6.58 23.30±3.54 19.83±3.40 0.000 0.084 0.482 0.110

L 16.93±5.12 17.46±4.67 19.49±4.36 19.14±4.04 0.443 0.973 0.023 0.000

Max-ADA
R 20.59±5.13 20.36±6.79 21.34±3.08 21.55±2.60 0.571 0.995 0.013 0.000

L**;# -13.39±3.46 -6.86±4.53 -4.23±6.42 -0.68±4.58 0.002 0.026 0.321 0.176

ISw-APA
R***;# -10.81±3.02 -8.33±4.41 -1.96±1.74 1.72±3.45 0.000 0.016 0.707 0.205

L* 2.25±2.57 5.82±4.55 9.10±5.20 9.54±5.32 0.012 0.313 0.219 0.039

MSw-ADA
R*** 3.47±2.91 5.71±2.94 11.83±2.08 12.41±2.42 0.000 0.149 0.709 0.078

L 8.56±4.59 7.86±4.79 7.13±4.38 8.21±5.03 0.461 0.994 0.021 0.000

TSw-ADA
R 7.78±3.88 6.02±4.04 7.64±1.48 8.23±1.61 0.341 0.589 0.035 0.011

317 Abbreviations: RoM, Range of motion; Max-, Maximum; L/R, Left/ Right.

318 Age significance, * denoted P<0.05; ** denoted P<0.01; *** denoted P<0.001.

319 Cane significance, # denoted P<0.05; ## denoted P<0.01; ### denoted P<0.001.

320

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321 Table 3 Statistical characteristics of the ground reaction forces (GRF)

Characteristics of Young Group Elderly Group P-value Effect size η2

the GRF (N/kg) Natural gait Cane gait Natural gait Cane gait Age Cane Age Cane

L-Fmax-1### 1.07±0.11 0.88±0.06 1.08±0.06 0.97±0.05 0.108 0.000 0.108 0.540

L-Fmin* 0.74±0.05 0.74±0.04 0.78±0.03 0.78±0.05 0.042 0.908 0.169 0.001

L-Fmax-2### 1.07±0.06 0.85±0.09 1.00±0.03 0.88±0.07 0.417 0.000 0.029 0.682

~60% of stance - - - 0.87±0.06

R-Fmax-1# 1.06±0.09 0.99±0.06§ 1.08±0.08 1.03±0.05§ 0.330 0.035 0.041 0.179

R-Fmin### 0.73±0.05 0.86±0.04§§ 0.76±0.04 0.84±0.03§§ 0.536 0.000 0.017 0.652

R-Fmax-2**;# 1.09±0.07 1.03±0.08§ 1.01±0.05 0.97±0.05§§ 0.005 0.034 0.294 0.180

~60% of stance - - - 0.95±0.03

L-BFmax## 0.19±0.05 0.11±0.06 0.16±0.03 0.13±0.02 0.783 0.003 0.003 0.322

L-DFmax### -0.17±0.03 -0.11±0.02 -0.15±0.02 -0.11±0.01 0.366 0.000 0.036 0.530

R-BFmax# 0.16±0.06 0.11±0.04 0.16±0.03 0.12±0.03 0.685 0.012 0.007 0.246

R-DFmax*;# -0.19±0.03 -0.15±0.04 -0.15±0.02 -0.13±0.01 0.019 0.012 0.218 0.244

L-LF1** -0.010±0.01 -0.012±0.01 -0.022±0.01 -0.020±0.02 0.003 0.720 0.319 0.006

L-ML1 0.059±0.01 0.047±0.02 0.050±0.02 0.043±0.08 0.625 0.598 0.011 0.012

L-ML2 0.049±0.01 0.026±0.02 0.045±0.01 0.030±0.06 0.369 0.824 0.035 0.002

R-LF1# -0.012±0.01 -0.007±0.01 -0.022±0.01 -0.016±0.01 0.137 0.034 0.094 0.182

R-MF1 0.056±0.01 0.040±0.02 0.047±0.02 0.037±0.02 0.455 0.053 0.024 0.153

R-ML2# 0.050±0.01 0.033±0.01 0.041±0.01 0.033±0.01 0.182 0.029 0.076 0.191

322 Age significance: * denoted P<0.05; ** denoted P<0.01;

323 Cane significance: # denoted P<0.05; ## denoted P<0.01; ### denoted P<0.001;

324 Left/right significance: § denoted P<0.05; §§ denoted P<0.01 (the young cane gait group: Effect size η2= 0.4~0.8; the elderly cane gait

325 group: Effect size η2=0.2~0.5).

326

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327
328 Fig.1. (A) Schematic diagram of experimental system, including Vicon Motion Capture Systems (12 motion capture cameras) and AMTI
329 Force plates (two force plates), (B) anatomical position marking points for plug-in-gait (PIG) models.

330

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331
332 Fig. 2. Joint angles of the left/right hip, knee and ankle in the sagittal plane. The abscissa represents the gait phases based on the left

333 heel, and the ordinate represents joint angle (°).

334 Abbreviations: Max-HEA (°) : maximum hip extension angle in pre swing phase; Max-HFA (°) : maximum hip flexion angle in mid

335 swing phase; MSt-KFA (°) : knee flexion angle in mid stance phase; Max-KFA (°) : maximum knee flexion angle in mid swing phase;

336 Max-ADA (°) : maximum ankle angle in terminal stance phase; ISw-APA (°) : ankle plantarflexion angle in initial swing phase; MSw-

337 ADA (°) : ankle dorsiflexion angle in mid swing phase; TSw-ADA (°) : ankle dorsiflexion angle in terminal swing phase.

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338
339 Fig. 3. (A) Schematic of the GRF of left lower extremity, (B) the vertical GRF (V-GRF), (C) the anterior-posterior GRF (AP-GRF) and

340 (D) the medial-lateral GRF (ML-GRF) of the left and right lower-extremities in the stance phase, normalized by body weight (%BW).

341 Abbreviations: L-Fmax-1, L-Fmax-2 and L-Fmin : the first peak, second peak and trough of V-GRF in left lower extremity; R-Fmax-1, R-Fmax-2

342 and R-Fmin : the first peak, second peak and trough of V-GRF in right lower extremity; L-BF and L-DF : the braking force and the

343 diving force of AP-GRF in left lower extremity; L-BFmax and L-DFmax : the braking force peak and driving force peak of AP-GRF in left

344 lower extremity; R-BFmax and R-DFmax : the braking force peak and driving force peak of AP-GRF in right lower extremity; L-MF : the

345 medial force of ML-GRF in the left lower extremity; L-LF1, L-MF1 and L-MF2 : the lateral force peak, first medial force peak and second

346 medical peak of ML-GRF in left lower extremity; R-LF1, R-MF1 and R-MF2 : the lateral force peak, first medial force peak and second

347 medical peak of ML-GRF in right lower extremity.

348

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