Abstract Stroke is a leading cause of long-term disability, with lower-limb weakness limiting mobility, independence, and quality of life among survivors. Limited access to sustained home-based rehabilitation, particularly in resource-constrained settings, underscores the need for practical, accessible interventions. This study evaluated the effectiveness of a home-based leg exercise device in improving lower-limb function among stroke survivors in Thailand. A quasi-experimental, repeated-measures design was conducted with 64 stroke survivors divided into two groups: an intervention group (n=32) and a control group (n=32). The intervention group engaged in a 12-week home-based rehabilitation program using a leg exercise device, while the control group received standard lower-limb exercises and a self-exercise manual. Outcomes, including lower-limb muscle strength, range of motion (ROM), and activities of daily living (ADL), were measured at baseline and at 1-, 2-, and 3-month follow-ups. Data were analyzed using repeated measures analysis of variance. Results demonstrated that the intervention group showed significantly greater improvements in lower-limb muscle strength compared with the control group throughout the 12 weeks (P < 0.05). Significant improvements were also observed in hip flexion and knee flexion ROM (P < 0.05), whereas hip extension and abduction showed no significant differences. ADL scores significantly improved in the intervention group at the 2- and 3-month follow-ups compared with the control group (P < 0.05). The home-based leg exercise device significantly improved lower-limb muscle strength, joint mobility, and functional ability among stroke survivors. This low-cost intervention may support community-based rehabilitation and promote functional independence, particularly in resource-limited settings.

Keywords: Stroke rehabilitation, Exercise therapy, Lower extremity, Muscle strength, Range of motion, Activities of daily living

Citation:  Pookongnak, U., Tanthanapanyakorn, P., Kanha, K., Nualphuean, N., Tokton, P., Whaithaisong, K., Khantikulanon, N., and Mungkhunthod, S. 2026. Effectiveness of a home-based leg exercise device for improving lower-limb function among stroke survivors in Thailand: A quasi-experimental study. Natural and Life Sciences Communications. 25(4): e2026094.

Graphical Abstract:

INTRODUCTION

Stroke is a leading cause of death and long-term disability worldwide, particularly among aging populations. It occurs when cerebral blood flow is disrupted due to arterial blockage, narrowing, or vessel rupture, resulting in permanent brain damage. Ischemic stroke accounts for more than 80% of cases, while hemorrhagic stroke comprises approximately 20% (World Health Organization, 2025). Clinical outcomes vary depending on the lesion site but commonly include unilateral motor weakness, sensory deficits, speech impairment, balance problems, and visual disturbances, which often persist beyond the acute phase and limit functional independence (Shahid et al., 2023; Hoh and Semrau, 2025). The global burden of stroke remains substantial, with approximately 17 million new cases and 6.5 million deaths reported in 2025, and more than 80 million people living with stroke-related disabilities (Feigin et al., 2025; World Health Organization, 2025). In Thailand, stroke incidence and mortality continue to rise, posing significant clinical, social, and economic challenges to individuals, families, and healthcare systems (Somsak, 2021; Ministry of Public Health, Thailand, 2025).

Following acute care, stroke survivors require continuous rehabilitation to restore function, prevent complications, and support reintegration into daily life. Among post-stroke impairments, lower-limb weakness is a key determinant of reduced mobility, balance, and independence, making targeted lower-limb rehabilitation essential for improving functional outcomes (Ahmad Ainuddin et al., 2021; Louie et al., 2022; Bai and Chen, 2025). However, in Thailand and similar settings, many survivors face challenges in maintaining consistent rehabilitation after discharge due to limited skills, insufficient support, and lack of accessible resources, resulting in poor adherence and delayed recovery (Deepradit et al., 2023; Ruksakulpiwat et al., 2025). These challenges are further intensified in community settings, where long travel distances, shortages of healthcare professionals, and increasing reliance on family caregivers often limit access to rehabilitation services. Socioeconomic constraints and changing family structures may reduce caregivers’ capacity to support long-term rehabilitation. In addition, stroke survivors frequently experience fatigue, depression, and reduced motivation, which contribute to low adherence to the rehabilitation program. Together, these factors highlight the need for practical, accessible, and sustainable home-based rehabilitation approaches (So and Park, 2024; Michael et al., 2025; Chingchit et al., 2026; Wungrath et al., 2026).

Although lower-limb function is essential for walking, fall prevention, and independent living, most rehabilitation research has focused on upper-limb recovery or therapist-led, facility-based interventions. Existing lower-limb rehabilitation approaches often require specialized equipment, professional supervision, or substantial caregiver involvement, limiting their feasibility in home and community settings, particularly in resource-limited contexts (Chin et al., 2022; Toh et al., 2022; Terathongkum and Kittipimpanon, 2023; Lo et al., 2025). Consequently, there is a critical need for simple, low-cost, and effective home-based rehabilitation devices that enable stroke survivors to perform consistent, self-directed lower-limb exercises. Therefore, this study aimed to evaluate the effectiveness of a home-based leg exercise device for improving lower-limb function among stroke survivors in Thailand. The findings were expected to contribute to the development of accessible rehabilitation strategies and support the integration of home-based interventions into community and primary care systems, particularly in resource-constrained settings.

MATERIALS AND METHODS

Study design

This study employed a quasi-experimental design with repeated measures across two groups, and the findings are reported in accordance with the TREND checklist (Des Jarlais et al., 2004). The objective was to evaluate the effectiveness of a home-based leg exercise device in improving lower-limb function, including muscle strength, range of motion (ROM), and activities of daily living (ADL), and to compare outcomes within and between the intervention and control groups. Outcome measures were assessed at four time points: baseline, 1-month, 2-month, and 3-month follow-ups. Participants in the intervention group received a 12-week home-based rehabilitation program using the leg exercise device, along with a standardized instruction manual. The control group received standard rehabilitation care, including conventional lower-limb exercises and a self-exercise manual, for the same duration.

Sample size

The sample size was calculated using G*Power for an F-test with repeated-measures ANOVA (within–between interaction) (Erdfelder et al., 2007). The calculation was based on a significance level of 0.05, a statistical power of 0.95, and a large effect size (Cohen's f = 0.40) (Cohen, 1977), yielding a minimum required sample of 52 participants. To account for potential attrition and data loss, the sample size was increased by 20%, resulting in a total of 64 participants, who were equally allocated to the intervention (n = 32) and control groups (n = 32).

Setting

The study was conducted in Sa Kaeo Province, Eastern Thailand, a predominantly rural area with limited access to tertiary hospitals and specialized rehabilitation services, particularly in remote communities (Sa kaeo Provincial Public Health Office, 2025). This setting was appropriate for evaluating a home-based leg exercise device, as many stroke survivors experience persistent lower-limb weakness after hospital discharge. The availability of local healthcare personnel and village health volunteers facilitated effective implementation and ongoing monitoring of the intervention.

Participants and sampling

The study population comprised 1,040 individuals with a medically confirmed diagnosis of stroke residing in Sa Kaeo Province, Thailand (Sakaeo Provincial Public Health Office, 2025). Participants were selected using a multi-stage random sampling approach. First, four of the nine districts, including Wattana Nakhon, Mueang Sa Kaeo, Khok Sung, and Aranyaprathet, were selected using simple random sampling with replacement, as these districts had comparable numbers of stroke survivors and similar sociodemographic characteristics. Second, potential participants were among these four districts, Wattana Nakhon was then selected using simple random sampling for participant recruitment selected from the patient registry of Wattana Nakhon Hospital. A total of 186 individuals were initially assessed for eligibility using predefined inclusion and exclusion criteria. After screening, 64 participants met the eligibility criteria and were enrolled in the study. These 64 eligible participants were then assigned to the intervention or control group using systematic alternate allocation based on the order of enrollment: participants were sequentially assigned to alternating groups as they were enrolled, yielding an intervention group (n=32) and a control group (n=32).

Inclusion criteria were adults aged 35 to 70 years with a diagnosis of stroke, residing in Sa Kaeo Province, with a stroke duration of ≤ 1 year, no medical complications, lower-limb motor power of at least Grade 1 (requiring close caregiver supervision for Grade 1), and ADL levels between 2 and 4 (Level 2 requiring supervision). Participants were required to understand Thai, provide informed consent (fingerprint permitted), and have access to a mobile phone. Caregivers were required to have at least one year of caregiving experience or cohabitation with the participant, and access to a mobile phone. Exclusion criteria included inability to attend scheduled activities, participation in another rehabilitation program, development of medical complications during the study period, or any condition that could interfere with study completion.

Intervention

This study assessed a 12-week, home-based leg exercise device further developed from the original Hand & Leg Skateboard innovation (Chen et al., 2017; Kumkwan et al., 2024; Krumina et al., 2025), which used hook-and-loop straps for horizontal sliding in patients with muscle weakness and limb pain. The device was redesigned for stroke rehabilitation with elastic leg straps to enhance safety, paired with a standardized exercise protocol combining horizontal- and vertical-plane movements to promote muscle activation, joint mobility, and progressive, safe training. The device was optimized for home use to support accessibility and long-term adherence following hospital discharge.

The intervention protocol was developed using Self-Efficacy Theory, which posits that individuals’ confidence in their ability to perform a specific behavior influences motivation, persistence, and adherence (Bandura, 1977). In this study, the program was designed to enhance patients’ confidence in independently and consistently performing home-based lower-limb exercises. The intervention was reviewed by a panel of five experts, comprising a family medicine physician, a physical therapist, a registered nurse, and two public health academics, to assess content validity, yielding a Content Validity Index (CVI) of 0.90, indicating excellent content validity. Experts were purposively selected based on clinical or academic backgrounds directly relevant to stroke rehabilitation. The panel was independent of the research and device development team and had no involvement in intervention design, thereby minimizing conflict of interest. To further reduce inter-rater influence, each member rated item relevance individually, and scores were compiled without group discussion.

The program comprised two core components: (1) structured lower-limb exercise training using the home-based leg exercise device and (2) an educational component aimed at strengthening self-management and adherence. Participants in the intervention group received the home-based leg exercise device and a standardized instruction manual for home-based rehabilitation. The researcher provided individual instruction, demonstration, and supervised practice before participants returned home. The program consisted of four lower-limb exercises performed using the device. Each exercise session lasted 10–15 minutes, conducted twice daily at least 5 days per week for 12 weeks. Initial resistance tension was individualized using the physiotherapist-guided Motor Power grade and Borg Rating of Perceived Exertion scale (Borg, 1982), targeting 10 repetitions at an exertion of 6–7/10. Repetitions remained at 10 during weeks 1–4, increased to 12–15 or an added set during weeks 5–8, and further increased to 16–20 repetitions or additional sets during weeks 9–12 according to individual tolerance. Exercises could be performed independently or with caregiver assistance when required. Participants and/or caregivers recorded exercise adherence in a weekly logbook provided by the researcher to monitor compliance and progression. Additionally, the control group received standard rehabilitation care, including a self-exercise manual and instructions for four lower-limb exercises following the same progressive repetition schedule (10 repetitions during weeks 1-4, 12–15 during weeks 5–8, and 16–20 during weeks 9–12), without the use of the exercise device. Demonstration and supervised practice were provided before home practice. Adherence was recorded using the same weekly logbook format (Table 1).

Outcome measures were evaluated at four time points: baseline, 1-month follow-up, 2-month follow-up, and 3-month follow-up. During the 12-week intervention, participants were monitored through weekly home visits conducted by the researcher and village health volunteers (VHVs) to assess exercise performance, provide feedback, and address barriers or adverse events. Additionally, ongoing progress reports were shared via a LINE group, where participants and caregivers were updated on exercise adherence, progress, any issues encountered, and any assistance required. Monthly formal evaluations (at 1, 2, and 3 months) included interviews and review of exercise logs conducted by the researcher, and physical performance tests conducted separately by the independent, blinded physiotherapist. Both the intervention and control groups received equal follow-up efforts to ensure consistency in monitoring.

The home-based leg exercise device was built from locally available, inexpensive materials. It features two wooden boards (1.5 cm thick; 35 × 15 cm and 15 × 15 cm) covered with rubber for safety and joined at a right angle with perforated steel brackets to create a stable frame. Swivel caster wheels were attached to the base for smooth horizontal movement. A flat rope with hanging loops offers hand support, and elastic bands (2.5 cm wide) with hook-and-loop fasteners provide adjustable leg fixation and resistance. To use, the affected leg is placed against the vertical board and secured with the elastic strap at the tension assigned by the physiotherapist. The participant holds the rope for stability and performs the prescribed lower-limb movements as instructed in the manual. The wheeled base allows controlled movement to support safe and structured muscle-strengthening exercises (Figure 1).

Figure 1. A home-based leg exercise device for lower-limb rehabilitation.

Measurement tool

The research tools used in this study included both researcher-developed questionnaires and standardized assessment instruments. The personal information questionnaire was developed based on a review of relevant literature and related studies (Keskaew et al., 2025; Somtua and Nuntaboot, 2025). Standardized instruments included the ADL scale (Mahoney and Barthel, 1965), the Motor Power grading scale (Paternostro-Sluga et al., 2008), and ROM measurement using a goniometer (Clarkson, 2000; Das et al., 2025). Assessments of ADL, motor power, and ROM were conducted solely by a single licensed physiotherapist from Wattana Nakhon Hospital, who was independent of the research team and blinded to group allocation.

Part 1: Personal Information Questionnaire. This section collected general data about stroke survivors, including sex, age, marital status, educational level, occupation, medical history, duration of stroke, and type of stroke.

Part 2: ADL Assessment. Functional ability was assessed using the Barthel Index of Activities of Daily Living, a 10-item scale with a maximum score of 20. Scores were categorized as follows: 0–4 (total dependence), 5–8 (severe dependence), 9–11 (moderate dependence), and 12–20 (mild or no dependence) (Mahoney and Barthel, 1965).

Part 3: Motor Power Assessment. Lower-limb muscle strength was graded from 0 to 5. Grade 5 indicates normal strength with full movement against gravity and resistance; Grade 4 indicates full movement against gravity with partial resistance; Grade 3 indicates full movement against gravity only; Grade 2 indicates movement in a horizontal plane without resistance; Grade 1 indicates visible or palpable muscle contraction without joint movement; and Grade 0 indicates no detectable muscle contraction (Paternostro-Sluga et al., 2008).

Part 4: ROM Assessment. Joint mobility was measured using a goniometer to assess the maximum range of motion at the lower-limb joints, reflecting the greatest possible movement without restriction (Clarkson, 2000).

To ensure the validity and reliability of the measurement instruments, content validity was assessed by a panel of three domain experts, comprising a medical specialist, a public health expert, and a rehabilitation professional. Index of Item–Objective Congruence (IOC) values ranged from 0.94 to 1.00, reflecting strong alignment with the study objectives. Face validity was further examined to confirm the clarity, appropriateness, and relevance of each item. Reliability was established through a pilot study conducted with 30 stroke survivors from the same geographic area who were not enrolled in the main study. The findings demonstrated satisfactory internal consistency across all instruments, with Cronbach's alpha coefficients of 0.92 for the ADL scale, 0.95 for the Motor Power grading scale, and 0.90 for ROM measurement.

Table 1. Home-based lower-limb exercise protocol using a leg exercise device.

Note: Repetitions progressively increased from 10 (weeks 1–4) to 12–15 (weeks 5–8) to 16–20 (weeks 9–12), or an additional set was added, based on individual tolerance.

Data collection

Data were collected in collaboration with Wattana Nakhon Hospital and community health networks in Sa Kaeo Province, Eastern Thailand. Ethical approval was obtained before recruitment, and coordination with hospital staff and VHVs ensured adherence to study procedures and eligibility criteria. Functional outcomes were assessed by a licensed physiotherapist using standardized measures, including ADL, lower-limb motor power, and ROM. Participants in the intervention group received supervised training using the home-based leg exercise device, along with an adherence logbook, while the control group received standard exercise instructions. Data were collected from August to December 2025 at four time points: baseline, 1-month, 2-month, and 3-month follow-ups. Adherence was supported through weekly home visits and communication via LINE, and monthly reassessments were conducted.

Ethical statement

This study was conducted in accordance with ethical principles for research involving human participants. Ethical approval was obtained from the Royal Patronage Ethics Committee at Valaya Alongkorn Rajabhat University (REC No. 0002/2025; COA No. 0072/2025), approved on August 15, 2025. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before they participated in the study. The study was registered with the Thai Clinical Trials Registry (TCTR20260311007).

Blinding

No blinding was used, as the quasi-experimental design and the visibly distinct device precluded participant or provider blinding; participants knew their group assignment. To reduce assessment bias, outcome evaluations were conducted by a single physiotherapist independent of intervention delivery and blinded to group allocation, using standardized tools and predefined procedures.

Bias

Several potential biases were considered. Selection bias may have arisen from incomplete allocation concealment despite multi-stage random sampling. Performance bias was possible, as participants knew their group assignment and device use may have influenced motivation. Measurement bias was minimized through standardized tools and single-physiotherapist evaluation. Reporting bias in self-reported logs was reduced via weekly home visits and online monitoring, while attrition bias was addressed through sample size inflation and regular 12-week follow-up.

Data analysis

Data were analysed using SPSS version 29.0.1 (IBM Corp.), with statistical significance set at P < 0.05. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize demographic characteristics and baseline variables. Baseline differences between the intervention and control groups were examined using the chi-square test or Fisher’s exact test, as appropriate. No statistically significant differences were observed between groups at baseline (P > 0.05), indicating comparability. To evaluate intervention effects over time, repeated-measures ANOVA (within–between interaction) was performed for lower-limb function outcomes, including motor power, ROM, and ADL, across four time points: baseline, 1 month, 2 months, and 3 months. Before analysis, statistical assumptions were assessed. The Kolmogorov–Smirnov test confirmed normality (P > 0.05), Levene’s test indicated homogeneity of variance (P > 0.05), and Mauchly’s test supported the assumption of sphericity (P > 0.05). As all assumptions were met, no corrections were applied. Effect sizes are reported as partial eta-squared (ηp²). Post hoc pairwise comparisons were conducted using the Bonferroni adjustment to control for type I error and to examine within- and between-group differences over time.

RESULTS

Participants flow

A total of 186 individuals were assessed for eligibility using predefined inclusion and exclusion criteria. Of these, 122 were excluded before enrollment: 78 did not meet the inclusion criteria, 12 were concurrently participating in another rehabilitation program, 14 were unable to attend the 12-week intervention or follow-up assessments, and 18 declined to participate or did not provide informed consent. A total of 64 eligible participants were enrolled and allocated equally to the intervention (n = 32) and control groups (n = 32). The intervention group received a 12-week home-based rehabilitation program using a leg exercise device along with a standardized instruction manual, while the control group received standard rehabilitation care and a self-exercise manual. No participants were lost to follow-up in either group. All participants completed assessments at baseline and at 1-, 2-, and 3-month follow-ups. All 64 participants were included in the final analysis, with no exclusions (Figure 2).

Exercise adherence

Exercise adherence was monitored throughout the 12-week intervention period using weekly logbooks and verified during home visits conducted by the researcher and village health volunteers. The mean adherence rate was 90.0% (SD ± 5.2%) in the intervention group and 85.0% (SD ± 10.2%) in the control group, indicating excellent compliance with the prescribed exercise protocol in both groups. The high levels of adherence observed across both groups suggest that the weekly monitoring, caregiver support, and ongoing communication via LINE were effective in sustaining consistent exercise practice throughout the study period.

Figure 2. Flow of participants through the study according to TREND guidelines.

Baseline data

    Table 2 presents the baseline demographic and clinical characteristics of the participants (n = 64). Overall, most participants were men (68.8%) and aged < 60 years (71.9%). The majority had completed at least senior high school education (85.9%), were married (53.1%), and reported a monthly income of 5,000–10,000 THB (62.5%). Most participants were employed (75.0%) and had at least one chronic condition (70.3%). Regarding stroke-related characteristics, 68.8% had a stroke duration of 1–6 months, and hemorrhagic stroke (59.4%) was more common than ischemic stroke (40.6%). Slightly more than half of the participants had left-sided weakness (53.1%). Most participants demonstrated mild or no dependence in ADL (73.4%). For lower-limb motor power, the majority had Grade 5 strength on both the left (64.1%) and right sides (57.8%). There were no statistically significant differences between the intervention and control groups in any baseline demographic or clinical variables (P > 0.05), indicating comparability between groups before the intervention.

Table 2. Baseline characteristics of the intervention and control groups (n=64).

Note. Values are presented as numbers (%) or mean ± standard deviation. THB, Thai baht; ADL, Activities of Daily Living. ^a) By chi-square test; significant difference (P < 0.05), ^b) By Fisher's exact test; significant difference (P < 0.05).

Effects of a home-based leg exercise device on lower-limb motor power

Repeated-measures ANOVA was performed to evaluate the effects of the 12-week home-based leg exercise device on lower-limb motor power over time between the intervention and control groups. The group × time interaction was used as the primary indicator of treatment effectiveness. As shown in Table 3, significant between-group differences were observed in lower-limb motor power for both the right (F = 7.40, P = 0.005) and left sides (F = 7.38, P =0.009). Significant time effects were also found (right: F = 22.18, P <0.001; left: F = 30.47, P <0.001), indicating overall improvement across measurement points. Importantly, significant group × time interaction effects were identified for both right (F = 7.85, P <0.001, ηp² = 0.112) and left motor power (F = 27.83, P <0.001, ηp² = 0.310), demonstrating that changes over time differed significantly between groups. Post hoc pairwise comparisons with Bonferroni adjustment (Table 4) showed no significant differences at baseline (right: P = 0.906; left: P =0.561), confirming baseline comparability. At 1-month follow-up, the intervention group demonstrated significantly greater improvements than the control group (right: Mean Difference [MD] = 0.469, P =0.038; left: MD = 0.480, P =0.042). These differences increased at 2 months (right: MD = 0.813, P < 0.001; left: MD = 0.906, P < 0.001) and were maintained or further enhanced at 3 months (right: MD = 0.781, P <0.001; left: MD = 1.250, P < 0.001). Overall, the home-based leg exercise device significantly improved lower-limb motor power compared with standard rehabilitation care. Improvements were evident from 1 month and became more pronounced over time, with sustained superiority at the 3-month follow-up.

Effects of a home-based leg exercise device on lower-limb ROM

Repeated-measures ANOVA demonstrated significant effects of the 12-week home-based leg exercise device on lower-limb range of motion (ROM) (Table 3). Significant between-group effects were observed for hip flexion on the right (F = 22.46, P < 0.001) and left sides (F = 10.59, P = 0.002), and for knee flexion on the right (F = 10.77, P = 0.002) and left sides (F = 13.57, P < 0.001). Significant group × time interaction effects were also identified for hip flexion (right: F = 35.66, P <0.001, ηp² = 0.365; left: F = 37.07, P <0.001, ηp² = 0.374) and knee flexion (right: F = 33.61, P <0.001, ηp² = 0.352; left: F = 27.74, P <0.001, ηp² = 0.309), indicating differential improvements over time. In contrast, hip extension and hip abduction on both sides showed no significant between-group or interaction effects (P >0.05). Post hoc Bonferroni comparisons (Table 4) confirmed baseline equivalence (all P >0.05). The intervention group demonstrated significantly greater improvements in hip flexion from 1 month onward (right: P < 0.001; left: P =0.015), with further gains at 2 and 3 months (all P ≤0.001). Similarly, knee flexion improved significantly at 1 month (both P = 0.003), with progressively larger differences at 2 months (P <0.05) and 3 months (both P <0.001). Overall, the home-based leg exercise device produced significant and sustained improvements in hip and knee ROM compared with standard rehabilitation care.

Table 3. Repeated measures ANOVA of variable outcomes between and within groups (n=64).

Note. ANOVA, analysis of variance; SS, sum of squares; df, degrees of freedom; MS, mean square; ROM, range of motion; ADL, Activities of Daily Living. Effect sizes (ηp²) are reported in the text. * Statistically significant at P < 0.05.

Effects of a home-based leg exercise device on ADL

Repeated-measures ANOVA demonstrated significant effects of the 12-week home-based leg exercise device on ADL (Table 3). A significant between-group effect was observed (F = 14.07, P < 0.001), along with a significant time effect (F = 62.63, P < 0.001), indicating overall improvement across assessment points. Importantly, a significant group × time interaction was identified (F = 6.13, P = 0.003, ηp² = 0.090), indicating differential changes between groups over time. Post hoc Bonferroni comparisons (Table 4) showed no significant difference at baseline (P = 0.614). Although the difference at 1 month did not reach statistical significance (P = 0.052), significant improvements favoring the intervention group were observed at 2 months (Mean Difference [MD] = 2.438, P = 0.026) and sustained at 3 months (MD = 2.219, P = 0.022). Overall, the home-based leg exercise device significantly improved ADL performance compared with standard rehabilitation care.

Table 4. Post-hoc pairwise comparison with Bonferroni correction of outcome variables between groups (n=64).

Note: Values represent mean differences between the intervention and control groups. SE, standard error; ROM, range of motion; ADL, Activities of Daily Living. *P <0.05. ^a) Bonferroni-adjusted for multiple comparisons; significant difference.

DISCUSSION

The 12-week home-based leg exercise device significantly enhanced lower-limb motor power compared with standard home-based rehabilitation. Improvements were observed at 1 month and continued to increase through 3 months, suggesting a progressive, dose-dependent response to the exercise program. Several mechanisms may explain these findings. First, the device allows repetitive, task-focused movements against controlled elastic resistance.   Resistance training and post-stroke neuroplasticity theory offer one possible explanation. Repeated submaximal contractions are thought to improve motor unit recruitment, firing synchronization, and cortical reorganization, processes linked to restoring voluntary activation in hemiparetic limbs (Phungdee et al., 2020). The present study did not measure these neurophysiological processes directly, and the observed motor power gains should therefore be read as consistent with, rather than direct evidence of, this mechanism. The gradual gains seen over time highlight the importance of ongoing, moderate-intensity resistance exercise in producing cumulative improvements in muscle strength. Second, the device's guided, multi-plane movements likely reduced fear of falling and built confidence in using the paretic limb, consistent with self-efficacy theory (Bandura, 1977; Ettefagh and Roshan Fekr, 2024). Third, the structured exercises, hip abduction–adduction, knee flexion–extension, hip bridge, and single-leg raise, target proximal and distal muscles vital for gait and balance (Ahmad Ainuddin et al., 2021; Chantharatsamee et al., 2025), while weekly monitoring and caregiver support reinforced adherence. Together, these findings indicate that the device offers a practical, effective approach to improving lower-limb motor power in stroke survivors. Chanpen et al. (2018) reported similar motor power gains using a multicomponent Thai traditional and alternative medicine program, while Rojo et al. (2024) achieved comparable improvements through device-assisted cycling in a smaller RCT. The present study extends these findings using a simpler, lower-cost home device with a larger community-based sample.

The 12-week home-based leg exercise device notably improved specific aspects of lower-limb ROM, particularly hip flexion and knee flexion on both sides, compared with standard rehabilitation. In contrast, hip extension and hip abduction showed no significant between-group differences or interaction effects. Principles of mechanotransduction and task-specific training can explain these findings. The exercise protocol emphasized repeated hip and knee flexion–extension movements, providing controlled, dynamic stretching under elastic resistance (Xiong et al., 2025). Repeated dynamic stretching is thought to improve tissue extensibility and joint mobility, which may explain the observed gains in active ROM over time. These tissue-level changes were not directly assessed in this study, and the ROM improvements should be interpreted as consistent with, rather than confirmation of, this mechanism. Since the device was mainly designed to facilitate sagittal-plane movements, greater gains were observed in hip and knee flexion, while movements less directly targeted showed fewer improvements (Sukonthamarn et al., 2019). Functionally, improved hip and knee flexion are essential for gait initiation, foot clearance during the swing phase, and sit-to-stand performance. Increased ROM in these joints may contribute to safer mobility and fewer compensatory patterns (Hosseini et al., 2019). The lack of significant changes in hip extension and abduction suggests that additional targeted exercises may be required to improve frontal-plane control and posterior chain flexibility. Unlike passive stretching, which shows inconclusive effects on post-stroke joint mobility (Gomez-Cuaresma et al., 2021), task-specific resistance protocols appear more effective, as seen with device-assisted cycling (Rojo et al., 2024) and task-oriented training (Khurshid et al., 2026). Home-based supervised programs also achieve outcomes comparable to hospital-based care (Basheikh and Badahdah, 2025), supporting the present community-based approach.

The 12-week home-based leg exercise device significantly improved ADL compared with standard rehabilitation. These improvements may be explained by enhanced lower-limb motor power and joint mobility, which are fundamental to daily activities such as transfers, walking, and stair negotiation. The structured, repetitive lower-limb exercises likely improved muscle strength, coordination, and movement efficiency, thereby facilitating greater independence. In addition, the home-based format, combined with caregiver involvement and weekly monitoring, may have reinforced adherence and self-management, consistent with self-efficacy theory (Bandura, 1977). The comparable and high adherence rates observed in both groups (90.0% vs 85.0%) further support the feasibility and acceptability of the home-based rehabilitation approach in this community setting (Paknapa et al., 2025). Increased confidence in performing exercises may translate into greater engagement in functional activities (Lee et al., 2022). From a functional perspective, improvements in ADL reflect not only physical recovery but also enhanced autonomy and reduced dependency (Lee and Kim, 2023; Chingchit et al., 2026). Chanpen et al. (2018) reported comparable ADL gains using a community-based program, consistent with these findings. Most prior ADL interventions, however, were delivered in inpatient settings (Triantis and Liu, 2024), highlighting a gap in home-based evidence that the present study helps address. Robot-assisted gait training has shown similar, though modest, ADL benefits (Lee and Kim, 2025), suggesting multiple intervention approaches can support functional independence after stroke.

Limitations

This study has several limitations that should be acknowledged. First, the quasi-experimental design without full randomization may introduce selection bias and limit causal inference. Second, blinding of participants and intervention providers was not feasible because of the visible, interactive nature of the home-based leg exercise device, which may have increased performance bias. Third, the study was conducted in a single rural province in Eastern Thailand, potentially limiting the generalizability of the findings to urban settings or populations with different healthcare systems.  Multi-site studies across diverse geographic and healthcare contexts are needed to confirm the external validity of these findings. Fourth, outcome assessment relied on manual muscle testing, goniometric ROM measurement, and the Barthel Index. Although a blinded, independent physiotherapist conducted outcome evaluation to minimize assessor bias, these instruments remain inherently subjective and, given the unblinded study design, susceptible to expectation bias, ceiling effects, and measurement variability. Objective performance-based measures, such as gait speed, the Timed Up and Go test, or the five-times sit-to-stand test, were not included, and their absence limits the strength of conclusions regarding functional mobility. Fifth, the device's validity was established only through content validity; construct validity, test-retest reliability, and biomechanical performance, such as resistance calibration and load consistency, were not formally evaluated in this study.  Sixth, exercise dose relied on self-reported logbooks without objective monitoring, so device-driven motivation, rather than the resistance mechanism alone, cannot be ruled out as contributing to the observed between-group differences. Finally, the relatively short follow-up period of 3 months limits the ability to assess the long-term sustainability of improvements in lower-limb function, including motor power, ROM, and ADL.

Recommendation for next study

Several directions for future research are suggested. First, randomized controlled trials involving larger and more diverse populations are needed to strengthen causal inference and enhance generalizability beyond rural community settings. Second, longer follow-up periods (e.g., 6–12 months or more) are required to evaluate the sustainability of improvements in lower-limb function, including motor power, range of motion (ROM), and activities of daily living (ADL), as well as potential effects on fall incidence, rehospitalization, and quality of life. Third, future research should also formally establish the device's reliability and biomechanical properties through resistance calibration, test-retest reliability testing, and electromyographic validation. Finally, implementation research is warranted to assess scalability, integration into health systems, caregiver burden, and long-term adherence in real-world community and primary care settings.

Implications for medicine and public health

Family medicine and community health professionals can integrate this device into continuity-of-care and self-management programs, using task-oriented, resistance-based exercise to build patient empowerment and long-term adherence. Community nurses and VHVs can support delivery through home visits and telemonitoring, reinforcing sustained practice. At the health system level, this low-cost approach can improve accessibility and equity within primary care, contributing to sustainable stroke rehabilitation in resource-limited settings.

CONCLUSION

The 12-week home-based leg exercise device significantly improved lower-limb muscle strength, hip and knee flexion range of motion, and activities of daily living among stroke survivors compared with standard home-based rehabilitation, with progressive gains sustained over 3 months. The device is low-cost, usable independently or with caregiver support, and addresses key barriers to post-stroke rehabilitation, making it a feasible and scalable option for community and primary care settings.

ACKNOWLEDGEMENTS

The authors would like to express their sincere appreciation to the healthcare staff and administrators of Wattana Nakhon Hospital, Sa Kaeo Province, Thailand, for their valuable cooperation and support throughout the data collection process. The authors gratefully acknowledge the physiotherapists and nurses for their professional assistance in delivering the rehabilitation program and supporting participant care during the study. In addition, the authors sincerely thank all participants for their time, commitment, and willingness to take part in this research. This study received no financial grants or external funding.

AUTHOR CONTRIBUTIONS

Unchalee Pookongnak: Conceptualization and Design (Lead), Data Acquisition (Lead), Investigation (Lead), Methodology (Lead), Project Administration (Supporting); Phannathat Tanthanapanyakorn: Conceptualization and Design (Supporting), Data Acquisition (Supporting), Tool Development (Lead), Formal Analysis (Lead), Data Interpretation (Lead), Investigation (Supporting), Methodology (Supporting), Project Administration (Lead), Resources (Lead), Visualization (Lead), Writing – Original Draft (Lead), Writing – Review & Editing (Lead); Kanyarat Kanha: Conceptualization and Design (Equal), Data Acquisition (Equal); Napha Nualphuean: Conceptualization and Design (Equal), Data Acquisition (Equal); Pornsiri Tokton: Conceptualization and Design (Equal), Data Acquisition (Equal); Kanjanaporn Whaithaisong: Conceptualization and Design (Equal), Data Acquisition (Equal), Investigation (Equal); Nonlapan Khantikulanon: Conceptualization and Design (Supporting), Tool Development (Supporting), Formal Analysis (Supporting), Methodology (Supporting); Sootthikarn Mungkhunthod: Review (Lead), Methodology (Supporting), Resources (Supporting), Supervision (Lead), Validation (Lead). All authors read and approved the final manuscript.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

CLINICAL TRIAL REGISTER

Trial Registry Number: Thai Clinical Trials Registry (TCTR20260311007)

AVAILABILITY OF DATA AND MATERIALS

The datasets are not publicly available but can be obtained from the corresponding author upon reasonable request.

REFERENCES

Ahmad Ainuddin, H., Romli, M.H., Hamid, T.A., Salim, M.S.F., and Mackenzie, L. 2021. Stroke rehabilitation for falls and risk of falls in Southeast Asia: A scoping review with stakeholders' consultation. Frontiers in Public Health. 9: 611793. https://doi.org/10.3389/fpubh.2021.611793

Bai, J. and Chen, K. 2025. Advances in nursing care for post-stroke limb dysfunction rehabilitation. Frontiers in Neurology. 16: 1615500. https://doi.org/10.3389/fneur.2025.1615500

Bandura, A. 1977. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review. 84(2): 191–215. https://doi.org/10.1037/0033-295X.84.2.191

Basheikh, M.A. and Badahdah, A.A. 2025. Efficacy of home-based physical exercise in stroke survivors: A systematic review and meta-analysis of randomized controlled trials. Archives of Rehabilitation Research and Clinical Translation. 7(4): 100494. https://doi.org/10.1016/j.arrct.2025.100494

Borg, G.A. 1982. Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise. 14(5): 377–381.

Chanpen, O., Leaungsomnapa, Y., Vasanat, P., Anusasanarak, S., Boonta, N., Khamdaengyodtai, Y., Prangsaowapha, K., and Prasertsri, N. 2018. Effects of integrative Thai and alternative medicine rehabilitative program on motor power and activity daily living in stroke patients. Journal of Phrapokklao Nursing College, Chanthaburi. 26(Suppl. 1): 60–71.

Chantharatsamee, B., Pochana, K., Trakarnchaisiri, P., and Thongkaew, K. 2025. Design and development of equipment for lower-limb muscle rehabilitation. Journal of Engineering and Innovation. 18(2): 92–100. 

Chen, C.C., Liu, C.Y., Ciou, S.H., Chen, S.C., and Chen, Y.L. 2017. Digitized hand skateboard based on IR-camera for upper limb rehabilitation. Journal of Medical Systems. 41(2): 36. https://doi.org/10.1007/s10916-016-0682-3

Chin, L.F., Rosbergen, I.C.M., Hayward, K.S., and Brauer, S.G. 2022. A self-directed upper limb program during early post-stroke rehabilitation: A qualitative study of the perspective of nurses, therapists and stroke survivors. PLoS One. 17(2): e0263413. https://doi.org/10.1371/journal.pone.0263413

Chingchit, W., Apichai, S., Thawisuk, C., Meenasak, P., Chaikham, A., and Dhippayom, J.P. 2026. Exploring post-stroke experiences of Thai community-dwelling stroke survivors and family caregivers: Implications for enhancing quality of life. Natural and Life Sciences Communications. 25(1): e2026014. https://doi.org/10.12982/NLSC.2026.014

Clarkson, H.M. 2000. Musculoskeletal assessment: Joint motion and muscle testing. Philadelphia (PA): Lippincott Williams and Wilkins.

Cohen, J. 1977. Statistical power for the behavioral sciences. 2^nd ed. New York (NY): Academic Press.

Das, U.C., Le, N.T., Vitoonpong, T., Prapinpairoj, C., Anannub, K., Akarathanawat, W., and Benjapolakul, W. 2025. An innovative model based on machine learning and fuzzy logic for tracking lower limb exercises in stroke patients. Scientific Reports. 15(1): 11220. https://doi.org/10.1038/s41598-025-90031-1

Deepradit, S., Powwattana, A., Lagampan, S., and Thiangtham, W. 2023. Effectiveness of a family-based program for post-stroke patients and families: A cluster randomized controlled trial. International Journal of Nursing Sciences. 10(4): 446–455. https://doi.org/10.1016/j.ijnss.2023.09.020

Des Jarlais, D.C., Lyles, C., Crepaz, N., and TREND Group. 2004. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND statement. American Journal of Public Health. 94(3): 361–366. https://doi.org/10.2105/ajph.94.3.361

Erdfelder, E., Lang, A.G., and Buchner, A. 2007. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 39: 175–191.

Ettefagh, A. and Roshan Fekr, A. 2024. Technological advances in lower-limb tele-rehabilitation: A review of literature. Journal of Rehabilitation and Assistive Technologies Engineering. 11: 20556683241259256.  https://doi.org/10.1177/20556683241259256

Feigin, V.L., Brainin, M., Norrving, B., Martins, S.O., Pandian, J., Lindsay, P., Grupper, M.F., and Rautalin, I. 2025. World Stroke Organization: Global stroke fact sheet 2025. International Journal of Stroke. 20(2): 132–144. https://doi.org/10.1177/17474930241308142

Gomez-Cuaresma, L., Lucena-Antón, D., González-Medina, G., Martín-Vega, F.J., Galán-Mercant, A., and Luque-Moreno, C. 2021. Effectiveness of stretching in post-stroke spasticity and range of motion: Systematic review and meta-analysis. Journal of Personalized Medicine. 11(11): 1074. https://doi.org/10.3390/jpm11111074

Hoh, J.E. and Semrau, J.A. 2025. The role of sensory impairments on recovery and rehabilitation after stroke. Current Neurology and Neuroscience Reports. 25(3): 23. https://doi.org/10.1007/s11910-025-01407-9

Hosseini, Z.S., Peyrovi, H., and Gohari, M. 2019. The effect of early passive range of motion exercise on motor function of people with stroke: A randomized controlled trial. Journal of Caring Sciences. 8(1): 39–44. https://doi.org/10.15171/jcs.2019.006

Keskaew, J., Piaseu, N., and Partiprajak, S. 2025. Needs of patients, family caregivers, and nurses in community-based stroke care. Journal of Thai Nurse Midwife Council. 40(4): 699–713.

Khurshid, H., Ezepue, M.H., Shah, S.M., Abbasi, J.Z., Nisa, M.U., Khan, W., Hassan, K., Wahid, E., and Ahmad, S. 2026. Task-oriented motor training improves lower extremity function in post stroke patients: A randomized control trial. Journal of Health, Wellness and Community Research. 4(6): 1-9. https://doi.org/10.61919/054h8v16

Krumina, K., Krumina, U., Mikelsone, A., Araka, L., Sprudza, K.L., Ziemele, G.M., and Semjonova, G. 2025. Smart device-based therapy on hand motor function improvement in stroke survivors during rehabilitation: A scoping review. JMIR Rehabilitation and Assistive Technologies. 12: e73533. https://doi.org/10.2196/73533

Kumkwan, Y., Utriyaprasit, K., Tankumpuan, T., Lertmanorat, Z., and Mathayomchan, B. 2024. Recovery after ischemic stroke: Effects of FuekFone home-based program on upper limb and cognitive function. International Journal of Nursing Sciences. 11(4): 414–420. https://doi.org/10.1016/j.ijnss.2024.08.008

Lee, J.H. and Kim, E.J. 2023. The effect of diagonal exercise training for neurorehabilitation on functional activity in stroke patients: A pilot study. Brain Sciences. 13(5): 799. https://doi.org/10.3390/brainsci13050799

Lee, J.H. and Kim, G. 2025. Effectiveness of robot-assisted gait training in stroke rehabilitation: A systematic review and meta-analysis. Journal of Clinical Medicine. 14(13): 4809. https://doi.org/10.3390/jcm14134809

Lee, K.E., Choi, M., and Jeoung, B. 2022. Effectiveness of rehabilitation exercise in improving physical function of stroke patients: A systematic review. International Journal of Environmental Research and Public Health. 19(19): 12739. https://doi.org/10.3390/ijerph191912739

Lo, Y.P., Wang, M.C., Chen, Y.H., Chiang, S.L., and Lin, C.H. 2025. Effectiveness of a post-acute-care rehabilitation program in patients with stroke: A retrospective cohort study. Life. 15(8): 1216. https://doi.org/10.3390/life15081216

Louie, D.R., Simpson, L.A., Mortenson, W.B., Field, T.S., Yao, J., and Eng, J.J. 2022. Prevalence of walking limitation after acute stroke and its impact on discharge to home. Physical Therapy. 102(1): pzab246. https://doi.org/10.1093/ptj/pzab246

Mahoney, F.I. and Barthel, D.W. 1965. Functional evaluation: The Barthel Index. Maryland State Medical Journal. 14: 61–65.

Michael, N.A., Mselle, L.T., Bureta, C.A., Ndile, M., and Cao, Y. 2025. Post-stroke recovery and home care challenges among stroke survivors and family caregivers in Tanzania: A qualitative study. BMC Nursing. 24(1): 1345. https://doi.org/10.1186/s12912-025-03929-6

Ministry of Public Health, Thailand. 2025. Percentage of patients diagnosed with stroke (intermediate care) receiving Thai traditional and alternative medical care. Nonthaburi (Thailand): Ministry of Public Health.

Paknapa, S., Yanawong, K., and Wungrath, J. 2025. Effectiveness of the E75 exercise program for strong and active elderly in improving physical fitness among older adults in Chiang Mai province, Thailand: A quasi-experimental study. Natural and Life Sciences Communications. 24: e2025054. https://doi.org/10.12982/NLSC.2025.054

Paternostro-Sluga, T., Grim-Stieger, M., Posch, M., Schuhfried, O., Vacariu, G., Mittermaier, C., Bittner, C., and Fialka-Moser, V. 2008. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. Journal of Rehabilitation Medicine. 40: 665–671. https://doi.org/10.2340/16501977-0235

Phungdee, T., Wattanathamrong, V., and Sirisopon, N. 2020. The effectiveness of a strengthening leg muscle physical exercise promotion program for preventing falls among older adults in Thailand. Interdisciplinary Research Review. 15(2): 19–23.

Rojo, A., Castrillo Calvillo, A., López, C., Raya, R., and Moreno, J. 2024. Effects of a virtual reality cycling platform on lower limb rehabilitation in patients with ataxia and hemiparesis: Pilot randomized controlled trial. JMIR Serious Games. 12: e39286. https://doi.org/10.2196/39286

Ruksakulpiwat, S., Benjasirisan, C., Phianhasin, L., Koson, N., Chei, N.E., Rounratana, T., and Thampakkul, J. 2025. Effectiveness of discharge planning interventions for stroke and heart conditions: A systematic review of interventional studies. Journal of Multidisciplinary Healthcare. 18: 7521–7537. https://doi.org/10.2147/JMDH.S563476

Sakaeo Provincial Public Health Office. 2025. Health annual report: Stroke patient data in Sa Kaeo Province 2025. Sa Kaeo (Thailand): Sa Kaeo Provincial Public Health Office.

Shahid, J., Kashif, A., and Shahid, M.K. 2023. A comprehensive review of physical therapy interventions for stroke rehabilitation: Impairment-based approaches and functional goals. Brain Sciences. 13(5): 717. https://doi.org/10.3390/brainsci13050717

So, J. and Park, M.H. 2024. Family's caregiving status and post-stroke functional recovery during subacute period from discharge to home: A retrospective study. Journal of Clinical Medicine. 13(22): 6923. https://doi.org/10.3390/jcm13226923

Somsak, S. 2021. Stroke situation in Thailand. Journal of the Neurological Society of Thailand. 37(4): 54–60.

Somtua, N. and Nuntaboot, K. 2025. Community-based rehabilitation for older adults post-stroke in Thailand: An ethnographic study. Belitung Nursing Journal. 11(2): 205–214. https://doi.org/10.33546/bnj.3690

Sukonthamarn, K., Rerkmoung, S., and Konjen, N. 2019. Effectiveness of anti-gravity treadmill training on walking capacity and balance in stroke patients. Journal of the Medical Association of Thailand. 102(9): 982–990.

Terathongkum, S. and Kittipimpanon, K. 2023. Effects of arm swing exercise program on HbA1C and nutritional status in adults and older adults with type 2 diabetes: A quasi-experimental study. Natural and Life Sciences Communications. 22(3): e2023048. https://doi.org/10.12982/NLSC.2023.048

Toh, S.F.M., Chia, P.F., and Fong, K.N.K. 2022. Effectiveness of home-based upper limb rehabilitation in stroke survivors: A systematic review and meta-analysis. Frontiers in Neurology. 13: 964196. https://doi.org/10.3389/fneur.2022.964196

Triantis, E. and Liu, K.P. 2024. Activities of daily living interventions on activity performance of inpatients post-stroke: A systematic review and meta-analysis. British Journal of Occupational Therapy. 87(10): 598–613. https://doi.org/10.1177/03080226241255021

World Health Organization. 2025. Stroke [Internet]. Geneva (Switzerland): World Health Organization; [cited 2025 Jul 12]. Available from: https://www.who.int/news-room/fact-sheets/detail/stroke

Wungrath, J., Chautrakarn, S., Tonloungkat, S., Chernbumroong, S., Boonprasit, K., Yanawong, K., Thasuwanain, T., and Wicha, S. 2026. Barriers to exercise among older adults in Northern Thailand: Insights from public health and community stakeholders. Natural and Life Sciences Communications. 25(1): e2026017. https://doi.org/10.12982/NLSC.2026.017

Xiong, B., Wang, X., Xu, X., Lou, Z., Tong, T., Gu, D., Zhang, K., and Liu, H. 2025. Effectiveness and safety of a lower-limb walking assist device for motor function recovery in subacute stroke patients: A prospective, randomized, open, parallel-controlled, noninferiority study. Journal of International Medical Research. 53(11): 3000605251396301. https://doi.org/10.1177/03000605251396301

OPEN access freely available online

Natural and Life Sciences Communications

Chiang Mai University, Thailand. https://cmuj.cmu.ac.th