Effects of gastrocnemius functional massage on lower extemity spasticity, spatio- temporal gait variables and fall risk in patients with stroke: A randomized controlled trial

Aziz Dengiz; Serbay Sekeroz; Emre Baskan; Güzin Kara

doi:10.1371/journal.pone.0332308

. 2025 Sep 24;20(9):e0332308. doi: 10.1371/journal.pone.0332308

Effects of gastrocnemius functional massage on lower extemity spasticity, spatio- temporal gait variables and fall risk in patients with stroke: A randomized controlled trial

Aziz Dengiz ¹, Serbay Sekeroz ^2,^*, Emre Baskan ³, Güzin Kara ³

Editor: Esedullah Akaras⁴

PMCID: PMC12459846 PMID: 40991570

Abstract

Aim

This randomized controlled clinical trial investigated the effects of gastrocnemius functional massage (GFM) combined with neurodevelopmental treatment (NDT) on spasticity, gait parameters, and functional mobility in stroke patients.

Methods

A total of 28 chronic stroke survivors were randomized into an experimental group (EG, n = 13) and a control group (CG, n = 15). Both groups received NDT twice a week for six weeks, while the EG received additional GFM. Spasticity (Modified Ashworth Scale), gait parameters (LegSys), and functional mobility (Timed Up and Go test) were assessed pre- and post-treatment.

Results

The results showed significant improvements in spasticity within the EG for the hip adductor (p = 0.002), knee extensor (p = 0.006), and ankle plantar flexor muscles (p = 0.002), compared to minimal changes in the CG (p > 0.05). Gait analysis revealed significant improvements in the EG for stride number (p = 0.0001), stride length (p = 0.006), stride time (p = 0.001), and stride velocity (p = 0.002), whereas the CG showed no significant changes (p > 0.05). Functional mobility improvements in the EG included reduced sit-to-stand time (p = 0.021) and total Timed Up and Go time (p = 0.001), indicating enhanced dynamic balance and lower extremity strength.

Conclusion

These findings suggest that combining GFM with NDT significantly enhances spasticity reduction, gait parameters, and functional mobility in stroke patients. Future studies are needed to explore the long-term effects and underlying mechanisms of this combined approach.

Clinical trial registration

This study was registered at www.clinicaltrials.gov under the identification number NCT06265753.

Introductıon

Spasticity is a common complication following a stroke, affecting approximately 43.2% of patients within the first year [1]. Among chronic stroke survivors with moderate to severe motor impairments, elevated muscle tone (spasticity) is observed in as many as 97% of cases [2]. From a biomechanical perspective, increased gastrocnemius muscle tone can exert excessive plantar force on the foot and ankle joints. Prolonged plantar positioning of the ankle may lead to joint dysfunction and restricted mobility, particularly in the talocrural joint. This condition often contributes to a range of deformities, such as equinovarus and toe deformities [3,4]. Inadequate ankle range of motion, combined with altered gastrocnemius and soleus muscle tone, results in impaired mobility, including asymmetric weight-bearing on the paretic leg, reduced gait speed, decreased cadence, and an increased risk of falls. Consequently, chronic stroke patients often experience significant limitations in daily activities [5–7].

A wide range of rehabilitation interventions has been employed to address post-stroke spasticity, improve gait function, and enhance balance. These include calf muscle stretching, strength training, weight-bearing exercises, orthoses, spasticity management techniques (e.g., botulinum toxin injections, medications), functional electrical stimulation training, proprioceptive control exercises, joint mobilization with movement, passive joint mobilization, and soft tissue massage [5,8,9]. Manual therapy approaches including soft tissue mobilization and joint mobilization manage tone problems such as spasticity through different mechanisms. These mechanisms are; providing non-noxious afferent input to regulate spinal reflex excitability, improving muscle-tendon viscoelastic properties, and providing proprioceptive input to increase quality movement [10–12].

Within this context, functional massage (FM) is a manual therapy technique that combines passive rhythmic mobilization with massage-stretching to reduce excessive muscle tone without causing pain [10]. Studies have shown that various mobilization techniques applied to the ankle joint post-stroke can improve spasticity, balance, gait, and reduce fall risk [11–13]. However, research specifically examining the effects of functional massage on the gastrocnemius muscle remains limited. Instrument-Assisted Soft Tissue Mobilization has shown potential to improve muscle tone and range of motion in conditions such as cerebral palsy and stroke [14,15]. Nevertheless, no studies to date have investigated the effects of functional massage targeting the gastrocnemius muscle on spasticity, gait metrics, and fall risk in stroke patients. The primary aim of this study was to examine the effects of functional massage applied to the gastrocnemius muscle twice a week over six weeks on spasticity, spatiotemporal gait features, and fall risk in stroke patients.

It was hypothesized that functional massage would significantly improve spasticity, gait parameters, and reduce fall risk in stroke patients.

Methods

Study design

We carried out this randomized controlled clinical trial in Physical Therapy Department at Pamukkale University Hospital. The local ethics committee of the university—Research Ethics Committee was approved with (E-60116787-020-474196) number—according to the Declaration of Helsinki (World Medical Association, Ferney-Voltaire, France, 2013), and was registered at www.clinicaltrials.gov under the identification number NCT06265753. The CONSORT 2010 standards were adhered to.

Participants

This study comprised a total of 28 participants who had experienced a stroke, (13 experimental group (EG), 15 control group (CG)). The participants were required to meet specific criteria in order to be included in the study. These criteria included: 1) having experienced a stroke at least 6 months prior, 2) being able to stand independently for at least 1 minute, 3) scoring at least 24 on the Standardised Mini-Mental State Examination (SMMSE), indicating no significant cognitive impairment [16], and 4) having lower extremity spasticity rated between 1–3 on the modified Asworth scale 5) at least 18 years of age. We excluded patients with comorbidities such as neurological, orthopaedic, metabolic, and rheumatological diseases that could potentially impact soft tissues. Additionally, we excluded patients who had received spasticity or other treatments that could affect soft tissues within the past 3 months, those with lower extremity injuries, and those with a diagnosis of cancer or who were pregnant. Participants were informed about the study procedure while a family member was present, and written informed consent was obtained from the participants.

Procedure

Participant recruitment and treatments of the study was conducted between May 2 and November 29, 2024. The group allocations by simple randomization was created using the website https://www.randomizer.org/ (Fig 1).

Both groups received NDT twice a week for six weeks, with the experimental group receiving 10 minutes of Gastrocnemius function massage (GFM) and the control group receiving 10 minutes of GFM sham application. The NDT was tailored to the patient’s needs and clinical status and lasted approximately 45 minutes.

Gastrocnemius Function Massage (GFM)

Functional Massage (FM) is a massage technique that combines joint movements with targeted pressure on tissues to address muscle and tendon pain as well as joint function limitations [17]. During FM application, pressure is applied to the tendons and soft tissues surrounding the muscles, while the muscles are alternately shortened and lengthened, resulting in joint movement. FM is commonly used to treat soft tissue adhesions, chronic and acute muscle tightness, muscle guarding reflexes, edema, swelling, and pain [17].

GFM was applied to reduce gastrocnemius muscle spasticity and to increase foot and ankle mobility in the participants. During the GFM application, the patient was positioned prone on an appropriate treatment bed. The patient’s foot was fixed between the therapist’s hip and ilium. The gastrocnemius muscle was grasped with both hands, and the ankle was pushed into dorsiflexion using support from the therapist’s trunk. Simultaneously, mobilisation was applied in the cranial direction, parallel to the gastrocnemius muscle fibres, with both hands. Finally, the therapist’s arm and trunk were gently pulled backwards until relaxation of the foot and gastrocnemius muscle was achieved. This application is continued rhythmically. The sham application was performed with the patient in the prone position with the hands touching the gastrocnemius muscle without any movement. GFM was performed by a physiotherapist with 11 years of experience in osteopathy and manual therapy.

Gastrocnemius sham application

The patient lay prone on the therapy table with the foot supported by a towel to maintain a slight flexion position. The therapist gently placed their hands on the gastrocnemius muscle without applying any pressure or stressing the tissues, maintaining this position throughout the procedure.

Neurodevelopmental Treatment (Bobath therapy) (NDT)

NDT, commonly referred to as the Bobath concept, is the most popular and frequently employed method for rehabilitating hemiparetic patients in Europe. Following injury to the central nervous system, NDT attempts to restore function. The goal of the NDT concept is to acquire complete independence in everyday living activities [18]. In order to optimise functionality, Bobath provides intensive exercise programmes that are integrated into daily life. These programmes focus on many aspects such as balance, gait, posture, muscle strength, and coordination. NDT emphasises movement quality, precision, task-orientation, intensity, and patient-orientation [19]. In this study, we used the NDT method in accordance with the patients’ needs for balance, weight transfer, trunk rotation exercises, upper extremity exercises, stair activities, and fine motor skill exercises as well as walking exercises (weight transfer, stepping, side walking, cross walking, backward walking, etc.). A physiotherapist with 11 years of experience and training in the current Bobath method carried out the NDT.

Outcome measurements

We elicted and documented participants’ demographic data, using a self-designed self-report form, and we assessed participant spasticity using Modified asworth scale (MAS), participant GP using spatial temporal gait analysis (LEGSystm), and participant fall risk using timed up and go test (TUG). We conducted these assessments twice, both pre and post treatments.

Modified Asworth Scale (MAS)

We used MAS to asses spasticity level of participants. The MAS is a tool used to evaluate the level of resistance encountered when performing passive range of motion, which does not require any instrumentation and is quick to perform (Bohannon and Smith, 1987). It is widely utilised to assess the effectiveness of pharmaceutical and rehabilitative therapies in treating and managing spasticity in patients with Stroke [20].

The scale is represented by the following numerical values [20].

0: No incrase in muscle tone

1: There is a small increase in muscular tension, with a slight resistance or moderate difficulty at the end of the range of motion when moving an affected body part(s) either flexion or extension.

1 + : A small increase in muscle tone is followed by minimal resistance across the remaining (less than half) of the range of motion.

2: There is a significant rise in muscular tension across most of the range of motion, but the affected part(s) can still be moved with ease.

3: Significant increase in muscle tone; difficulty with passive movement

4: Affected part(s) rigid in flexion or extension

The MAS (0, 1, 1 + , 2, 3, 4) was produced by Bohannon and Smith in 1987. “0, 1, 2, 3, 4, 5” scoring is employed for MAS in a number of investigations [21,22].

We recorded the spasticity levels of the subjects’ hemiparetic quadriceps femoris, hip adductor, and gastrocnemius muscles. Furthermore, the overall MAS score was calculated for the affected lower extremity by aggregating all the data. The overall agreement was very good, with a kappa value of 0.87 [23].

Spatial Temporal Gait Analysis (Legsystm)

We evaluated the participants’ walking variables with a wearable walking analysis device called Legsystm. The data collected by two sensors attached to supramalleolar area with velcro is communicated and analysed to the accompanying computer via bluetooth. Legsystm has the capability to conduct various measurements of spatio-temporal data collected from participants. In Legsystm analysis, we asked participants to complete the timed up and go test [24,25].

Timed up and Go Test (TUG) with legsystm

We employed the Timed Up and Go (TUG) test to assess the spatio-temporal parameters and determine the risk of falling in stroke patients. During the TUG test, the patient is first seated in a suitable chair. They are then directed to stand up, walk a specified distance of 3 metres, and then return to the chair.. Stroke patients with balance impairments are at a significantly elevated risk of falling, with the prevalence of falls reaching up to 73% [26].

Sample size

We used G*Power 3.19 (Heinrich Heine University, Dusseldorf, Germany) for sample size calculations [27]. Based on a reference study reporting mean (±SD) changes of 0.877 ± 0.799 in the treatment group and −0.279 ± 0.729 in the control group, the estimated effect size (Cohen’s d) was calculated as approximately 1.51 [25]. Using G*Power, a sample size of 11 participants per group was determined to achieve 95% power at a 5% significance level. To account for an anticipated ~25% dropout rate, we planned to recruit 15 participants per group, resulting in a total sample of 28 participants with 2 drop out from control group.

Statistical analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 23.0 (SPSS Inc., Chicago, IL). The normality of all continuous variables was assessed using the Shapiro-Wilk test as well as skewness and kurtosis values. Since the assumptions of parametric tests were not satisfied, the Mann-Whitney U test was applied for comparisons between groups, and the Wilcoxon Signed-Rank test was used for within-group comparisons. The level of significance was set at p < 0.05.

Results

The demographic and clinical data of the groups were presented in Table 1. Participants in both groups were similar in terms of age, height, weight, BMI, stroke duration, type, affected side, and disability level (p > 0.05).

Table 1. Comparison of demographic and clinical values of stroke patients.

	EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	z	p
Age (year)	54.0 (30–68)	55.0 (30–73)	−0.116	0.908
Height (cm)	165 (150–175)	170 (147–175)	−0.791	0.429
Weight (kg)	73 (60–86)	70 (63–82)	−0.488	0.626
BMI (kg/m ²⁾	26.06 (22.04–31.25)	26.12 (22.86–31.93)	−0.161	0.872
Stroke Duration (month)	34 (5–72)	45 (5-120)	−1.041	0.298
Modified Rankin Scale	2 (1–3)	2 (2–3)	−0.984	0.325
	n (%)	n (%)	df	p
Stroke type Ischemic Hemorrhagic Embolic	11 (84.6) 1 (7.7) 1 (7.7)	11 (73.3) 3 (20) 1 (6.7)	2	0.650
Affected side Right Left	7 (53.8) 6 (46.2)	5 (33.3) 10 (66.7)	1	0.274

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EG: Experimental group, CG: Control group n: Number of cases, Min-Max: Minimum-Maximum, z: Mann Whitney U test, kg/m²: Kilogram/square meter, BMI: Body mass index, p < 0.05.

Intra-group and inter-group comparisons of spasticity values were presented in Table 2. The current study showed that the EG significantly reduced spasticity in hip adductor muscles (p = 0.002), knee extensor muscles (p = 0.006), and ankle plantar flexor muscle (p = 0.002) while CG reduced in hip adductor muscles (p = 0.018). Furthermore, comparison of changes after treatment revealed that spasticity in the ankle plantar flexor muscle decreased significantly more in EG than in CG (p = 0.002).

Table 2. Comparison of spasticity values of stroke patients.

		EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	IQR (EG/CG)	z	p^a
Hip adductor muscles	Pre-Treatment	3 (2-4)	3 (1-3)	(1.00/1.00)	−.387	0.699
	Post-Treatment	2 (1-2)	2 (1-3)	(1.00/1.00)	−1.174	0.240
	Delta (Δ)	1	0	(0.00/1.00)	−1.824	0.068
	w	66	28
	p ^b	0.002	0.018
Knee extensor muscles	Pre-Treatment	1 (1-2)	2 (0-3)	(1.00/1.00)	−0.104	0.917
	Post-Treatment	2 (1-3)	2 (0-3)	(1.00/1.00)	−1.556	0.12
	Delta (Δ)	1 (0-2)	0 (−1-2)	(1.00/1.00)	−1.725	0.085
	w	45	22
	p ^b	0.006	0.187
Ankle Plantar Flexor muscle	Pre-Treatment	3 (2-4)	3 (1-4)	(1.00/1.00)	−0.352	0.725
	Post-Treatment	1 (1-2)	2 (1-3)	(1.00/1.00)	−2.741	0.006
	Delta (Δ)	1 (0-2)	0 (−1-2)	(1.00/1.00)	−3.064	0.002
	w	78	21
	p ^b	0.002	0.24

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EG: Experimental group, CG: Control group, IQR: Interquartile range, Min-Max: Minimum-Maximum, p^a: Intergroup comparison, p^b: Intragroup comparison, z: Mann Whitney U test, w: Wilcoxon Signed Rank test, p < 0.05.

Intra-group comparisons of gait parameters showed that stride number (p = 0.002), stride length (p = 0.005), stride time (p = 0.002), and cadence (p = 0.004) were statistically changed in EG, but there was no statistical change in the CG. Additionally, comparison of changes after treatment revealed that stride length (p = 0.006), stride velocity (p = 0.002), and cadence (p = 0.002) increased and stride number (p = 0.0001) and stride time (p = 0.001) decreased significantly more in EG compared to CG (see Table 3).

Table 3. Comparison of basic gait parameters of stroke patients.

		EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	IQR (EG-CG)	z	p^a
Stride number	Pre-Treatment	12 (6-32)	11 (5-18)	(7 - 4.5)	−0.786	0.432
	Post-Treatment	9 (5-15)	11 (5-20)	(4 - 4.5)	−1.945	0.052
	Delta (Δ)	3 (0-19)	0 (−7−4)	(3 - 1.5)	−3.646	0.0001
	w	78	15
	p ^b	0.002	0.218
Stride length	Pre-Treatment	0.6 (0.07-1.24)	0.55 (0.33-1.16)	(0.13 - 0.155)	−1.153	0.249
	Post-Treatment	0.76 (0.38-1.44)	0.57 (0.33-1.2)	(0.15 - 0.21)	−2.005	0.045
	Delta (Δ)	−0.13 (−0.31-0.11)	0.00 (−0.7-0.16)	(0.1–0.095)	−2.766	0.006
	w	4.5	55
	p ^b	0.005	0.90
Stride time	Pre-Treatment	1.44 (1.06–2.3)	1.43 (1.05–1.82)	(0.29 - 0.275)	−0.392	0.695
	Post-Treatment	1.2 (0.99–1.71)	1.5 (0.28–1.8)	(0.28–0.32)	−2.813	0.005
	Delta (Δ)	0.25 (−0.05–1.10)	−0.02 (−0.45–1.08)	(0.12–0.13)	−3.25	0.001
	w	89.5	41
	p ^b	0.002	0.49
EG: Experimental group, CG: Control group, IQR: Interquartile range, Min-Max: Minimum-Maximum, p^a: Intergroup comparison, p^b: Intragroup comparison, z: Mann Whitney U test, w: Wilcoxon Signed Rank test, p < 0.05.
		EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	IQR (EG-CG)	z	p ^a
Stride velocity	Pre-Treatment	0.45 (0.04-0.85)	0.39 (0.18-1.10)	(0.14 −0.17)	−1.014	0.311
	Post-Treatment	0.6 (0-0.98)	0.36 (0.16-1.0)	(0.11–0.20)	−2.282	0.023
	Delta (Δ)	−0.15 (−0.37-0.45)	0.00 (−0.1-0.17)	(0.15–0.08)	−3.044	0.002
	w	18	62.5
	p ^b	0.059	0.248
Cadence	Pre-Treatment	83.8 (53–114)	86 (66 - 114)	(18–16.8)	−0.230	0.818
	Post-Treatment	98 (70.3–122)	88 (70–110)	(10–21)	−2.051	0.04
	Delta (Δ)	−11 (−27–4)	−0.84 (−12.1–16)	(18.2–5.15)	−3.135	0.002
	w	2	48
	p ^b	0.004	0.801
EG: Experimental group, CG: Control group, IQR: Interquartile range, Min-Max: Minimum-Maximum, p^a: Intergroup comparison, p^b: Intragroup comparison, z: Mann Whitney U test, w: Wilcoxon Signed Rank test, p < 0.05.

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Across multiple components of the Timed up and Go test, sit to stand (p = 0.021), walk out (p = 0.025), mid turn (p = 0.001), end turn (p = 0.004), and total time (p = 0.001) were statistically decreased in EG, but there was no statistical improvement in the CG. Comparison of the changes obtained after treatment in both groups showed that mid turn (p = 0.001), walk back (p = 0.002) and total time (p = 0.001) decreased significantly more in EG than in CG (see Table 4).

Table 4. Comparison of timed up and go test times of stroke patients.

		EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	IQR (EG – CG)	z	p^a
Sit to stand (sec)	Pre-Treatment	5.44 (3–7.16)	5.9 (4–8.49)	(1.37–2.52)	−0.898	0.369
	Post-Treatment	4 (3–5.47)	5.53 (3–8)	(1.49–1.83)	−2.653	0.008
	Delta (Δ)	0.94 (−0.81 −4.16)	0.0 (−3.5–3.35)	(1.6–0.875)	−1.221	0.222
	w	78	49
	p ^b	0.021	0.456
Walk out (sec)	Pre-Treatment	6.00 (3.75–29.8)	5 (1.04–13.2)	(2.75–3.89)	−1.060	0.289
	Post-Treatment	4.73 (3–11.1)	4.71 (1.60 - 18)	(1.36 - 4.86)	−0.3	0.764
	Delta (Δ)	2 (−1.61- 18.7)	0.09 (−14–2.67)	(3.64 - 1.13)	−1.728	0.084
	w	68	56
	p ^b	0.025	0.485
Mid turn (sec)	Pre-Treatment	4.38 (2.2–14.5)	3.8 (0–8.76)	(1.36–1)	−1.129	0.259
	Post-Treatment	3 (2- 5.36)	3.8 (1–8.7)	(1.56 − 1)	−1.775	0.076
	Delta (Δ)	1.1 (−0.36–9.38)	−0.01 (−1–1.41)	(1.01–0.395)	−3.480	.001
	w	89	37
	p ^b	0.001	0.576
End turn (sec)	Pre-Treatment	1.72 (1.0–6.0)	2.3 (0.62–5.0)	(1.13–4.93)	−0.968	0.333
	Post-Treatment	1.5 (0.86–4)	2.06 (1.0–5.68)	(1.48–3.62)	−1.246	0.213
	Delta (Δ)	0.25 (−2.21–3.97)	0.12 (−3.0–0.98)	(1.64–1.51)	−0.392	0.695
	w	87	50
	p ^b	0.004	0.78
EG: Experimental group, CG: Control group, IQR: Interquartile range, Min-Max: Minimum-Maximum, p^a: Intergroup comparison, p^b: Intragroup comparison, z: Mann Whitney U test, w: Wilcoxon Signed Rank test, sec: Second, p < 0.05.
		EG (n = 13) Median (Min-Max)	CG (n = 15) Median (Min-Max)	IQR (EG – CG)	z	p ^a
Walk back (sec)	Pre-Treatment	5.53 (4.0–32.1)	5.55 (2.0–11.8)	(1.13–4.93)	−0.553	0.58
	Post-Treatment	3.53 (2.67–8.41)	6.50 (2.0–12.0)	(1.48–3.62)	−1.867	0.062
	Delta (Δ)	2.0 (−1.22–23.7)	0.0 (−9.0–2.24)	(1.64–1.51)	−3.157	0.002
	w	63	70
	p ^b	0.244	0.286
Stand to sit (sec)	Pre-Treatment	3.11 (0.61–4.10)	2.0 (0.5–6.12)	(2.07–1.67)	−1.359	0.174
	Post-Treatment	1.66 (0.15–5.0)	1.69 (0.5–7.0)	(1.50–1.68)	−0.553	0.58
	Delta (Δ)	0.20 (−1.56–3.25)	−0.05 (−2–2.39)	(2.39–0.58)	−1.590	0.112
	w	67	32.5
	p ^b	0.146	0.638
Total (sec)	Pre-Treatment	27.1 (16.4–94.0)	24.0 (9.0–51.2)	(10.0–10.5)	−0.806	0.42
	Post-Treatment	19.8 (13.6–29.0)	26.0 (14.6–49.4)	(5.6–9.85)	−2.257	0.024
	Delta (Δ)	6.44 (−2.74–65.0)	0.88 (−25.4–6.21)	(6.23–3.56)	−3.325	0.001
	w	89	61.5
	p ^b	0.001	0.594
EG: Experimental group, CG: Control group, IQR: Interquartile range, Min-Max: Minimum-Maximum, p^a: Intergroup comparison, p^b: Intragroup comparison, z: Mann Whitney U test, w: Wilcoxon Signed Rank test, p < 0.05.

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Discussion

The present study demonstrated that gastrocnemius functional massage applied to stroke patients in the experimental group resulted in significant improvements in spasticity, gait parameters, and functional mobility compared to the control group. Moreover, incorporating GFM into NDT further enhanced rehabilitation outcomes, indicating that the combination of GFM and NDT may offer greater effectiveness in post-stroke recovery.

Spasticity, a common consequence of stroke, negatively affects functional characteristics of individuals such as walking, personal care, mobility, and transfer [28]. In our study, the reductions in muscle tone, especially in the hip adductor and ankle plantar flexor muscles, were significant in EG. The post-treatment improvements in MAS scores indicate that adding GFM to the NDT effectively reduced spasticity. Tone problems, which impedes the range of motion and functional activities such as walking and transferring, was notably reduced, aligning with previous studies that highlight the effectiveness of manual therapy interventions in spasticity management [12,29–31]. Parikh et al. [32] showed that manual therapy—specifically myofascial release—can significantly reduce spasticity and increase joint mobility in stroke patients. Similarly, joint mobilizations targeted at enhancing lower limb mobility resulted in better functional outcomes [12,31]. These results are supported by our findings, especially the decrease in ankle plantar flexor spasticity, which suggests that manual therapy techniques targeting the soft tissues may play a critical role in reducing spasticity. Our results suggest that adding manual interventions (gastrocnemius function massage) to NDT may have specifically targeted the neural mechanisms underpinning muscle tone regulation. Future studies could examine the mechanistic pathways by which manual therapies affect spasticity and guide more effective rehabilitation plans.

Stroke patients often display compensatory gait patterns due to muscle spasticity, impaired balance, and weakness. Notable improvements in gait parameters highlight the potential of our intervention to improve ambulatory function. Post-treatment improvements in stride length and velocity in our study group suggest enhanced motor control. Manual therapy techniques, including soft tissue mobilization, are known to improve joint mobility and muscle flexibility, which can improve gait patterns. The research by Cho and Park [12] showed that joint mobilization can enhance the joint range of motion and function in stroke patients, resulting in better gait performance. Similarly, previous research [33] has shown that rehabilitation strategies targeting soft tissue can significantly enhance functional gait performance in stroke patients. Furthermore, improved muscle coordination, which has been demonstrated to benefit from manual therapies, may be related to the beneficial effects on cadence seen in the current study [34,35]. The decrease in stride time observed in our results, consistent with the study by Kim et al. [36], may be related to increased dynamic balance ability and reduced compensation during walking. By addressing underlying biomechanical dysfunctions, GFM techniques that enhance joint and muscle function are important to improve gait parameters.

Our results of the TUG test showed significant improvements in functional mobility in the study group, with a significant reduction in total TUG time. This situation demonstrates increased motor efficiency and coordination, which are critical for daily functions such as transfer, turning, and walking. The decrease in sit-to-stand time in our study group suggests increased dynamic balance and lower extremity strength. The beneficial results seen in our study are similar to studies showing that manual therapy techniques such as myofascial release and joint mobilizations significantly increase functional mobility [25,37]. Additionally, the increase in mid-turn time in the current study points to improved dynamic stability and postural control. Manual therapy techniques targeting the soft tissues around the pelvis, spine, and lower extremities have been shown to increase postural control during dynamic functions like turning [38].

The strength of our study is that it was conducted as a randomized and controlled study. Naturally, like any study, ours has some limitations. First, the long-term effectiveness of the treatments was not evaluated. Second, no blinding was implemented in this study.

The conclusion of this study highlights the potential of adding gastrocnemius function massage to NDT as an effective treatment option for improving spasticity, gait parameters, and functional mobility in stroke patients. These improvements may have significant clinical implications, including enhanced independence, reduced risk of fall, and improved quality of life for stroke survivors. Further studies that will optimize the intervention protocol and evaluate its cost-effectiveness will be beneficial for the rehabilitation process of stroke patient.

Supporting information

S1 Data. CONSORT Checklist: The checklist provides detailed guidance on the essential methodological and reporting items addressed in the study.

(DOC)

pone.0332308.s001.doc^{(219.5KB, doc)}

S2 Text. Study Protocol in English: This document provides the full study protocol in English, detailing the study design, objectives, inclusion and exclusion criteria, procedures, outcome measures, and analysis plan to ensure transparency and reproducibility.

(DOCX)

pone.0332308.s002.docx^{(19.3KB, docx)}

S3 Text. Study Protocol in Turkish: This document provides the full study protocol in Turkish, detailing the study design, objectives, inclusion and exclusion criteria, procedures, outcome measures, and analysis plan to ensure transparency and reproducibility.

(DOCX)

pone.0332308.s003.docx^{(41.6KB, docx)}

S4 Data. Minimal data set: This file contains the minimal anonymized data set underlying the findings of the study, provided in a format that allows independent verification of the analyses presented in the manuscript.

The dataset includes all relevant variables necessary to replicate the results while ensuring participant confidentiality.

(XLSX)

pone.0332308.s004.xlsx^{(20KB, xlsx)}

Acknowledgments

The authors thanks to all participants.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0332308.r001

Decision Letter 0

Esedullah Akaras

19 Jun 2025

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: The investigators used G*Power 3.19 (Heinrich Heine University, Dusseldorf, Germany) for sample size calculations. Based on an expected effect size of 1 (statistical power of.80 and error probability of.05), They computed the total estimated required sample size for acceptable statistical power to be 28 (14 in the EG, 14 in the CG). This is insufficient information. What were the precise differences sought with standard deviations, effect sizes, etc? The protocol in the Appendix is insufficient and lacks this information as well. Also, these calculations should be checked against a more standard clinical trials sample size software such as Power and Precision or other relevant tool such as PASS.

The analysis performed looks somewhat reasonable. However, Tables 2 to 4 show many statistical comparisons being made. A p=value adjustment for multiple comparisons should be examined as those like p=0.04 or 0.025 may not be statistically significant. What are the primary and secondary endpoints? How does this affect the setting of the alpha levels for appropriate adjustment? Also, the Statistical Analysis section refers to normal tests. However, the Tables presented look to be done non parametrically. If normality was assumed, then the confidence intervals would be helpful in determining the reliability of the results. Please explain. The paper needs a thorough edit to be sure appropriate detail is provided.

Reviewer #2: 1. It would be useful to include some important demographic details in this section, such as gender distribution, stroke etiology (ischemic/hemorrhagic), and affected side (right/left).

2. GFM Definition: The detailed description of the Gastrocnemius Function Massage (GFM) application is commendable. However, some expressions (for example: “the therapist gently pulls the arm and trunk backwards until the foot and gastrocnemius muscle relaxes”) need clarification in terms of anatomy and biomechanics. Do the terms “arm” and “trunk” here refer to the therapist’s or the patient’s trunk? Unclear.

3. Sham GFM: The “sham” method applied to the control group provides a valid comparison, but the extent to which the procedure was effective in terms of blinding (e.g., whether participants guessed their group) is not specified.

4. Gap: The fact that NDT was administered to all participants suggests that GFM was the only variable; however, more information on session length and degree of individualization in content for NDT would be helpful.

5. MAS: The explanations are sufficient, but it is not stated how many different assessors made the assessments and whether the assessors were blinded.

6. Gait Analysis - Legsystm: Adequate technical explanation is given. However, it would have been appropriate to refer to the validity and reliability information of the device.

7. Deficiency: Taking the effect size as 1 is a very high assumption. It should be stated which source or preliminary study this value is based on.

8. Sentence structures should be simplified; especially the part explaining the GFM application should be written in clearer and more technical terms.

9. A reference to the effect size used in the sample size calculation should be provided.

10. It should be stated whether the person(s) performing the spasticity assessment are the same person and whether blindness is ensured.

11. There are grammar and fluency problems in some sentences. Example: In the sentence “Participants in both groups had similar in terms of…” the expression “had similar” is used incompletely. The correct usage should be “were similar in terms of…”

Reviewer #3: 1. Title & Abstract

Strengths:

The title is clear, specific, and reflects the key outcomes of the study.

The abstract is structured and summarizes aim, methods, results, and conclusion.

Suggestions:

Consider adding "stroke patients" to the keywords for better indexing.

The final sentence about long-term outcomes could be omitted in the abstract (due to word limits) and moved to the conclusion section of the main text.

Introduction

Strengths:

Provides a solid overview of the prevalence and impact of spasticity post-stroke.

Clear rationale and identification of the research gap.

Suggestions:

The hypothesis (H1) should be rephrased in academic style, e.g., “It was hypothesized that functional massage would significantly improve...”.

Methods

Strengths:

Ethical approval and clinical trial registration are well-documented (a strong point).

The sham-controlled design is commendable.

Clear inclusion/exclusion criteria.

Critiques:

"10 GFM sham application" likely contains a typo — should be “10 minutes of sham GFM”.

MMSE cut-off is listed as 23 — typically, 24 is used. Clarify with reference.

Results

Strengths:

Statistical tests are appropriate.

Tables are referenced, and p-values are reported clearly.

Suggestions:

Verify consistency between text and tables (e.g., changes in cadence or stride parameters).

Discussion

Strengths:

Thorough and well-supported with citations.

Proper alignment of results with existing literature.

Strengths and limitations are acknowledged.

Suggestions:

Some explanations (especially about the mechanism of GFM) are slightly repetitive — could be condensed.

Blinding details are not discussed. Was this single-blind or double-blind?

Language & Style

Critiques:

Several minor spelling errors (e.g., “muslce” → “muscle”, “spacticity” → “spasticity”).

Avoid direct instructions or first-person tone in the methods section.

Overall Assessment

Strengths:

This is a well-designed randomized controlled trial with a novel approach.

Use of a sham group strengthens the internal validity.

Results have meaningful clinical implications.

Weaknesses:

The blinding protocol is unclear.

Final Recommendation

This study provides important insights into post-stroke rehabilitation using manual therapy techniques. With revisions in tone, style, minor methodological clarifications.

Minor revision

Reviewer #4: The manuscript aims to highlight the beneficial effects of functional massage applied in association with neurodevelopmental treatment on lower limb spasticity, within a rehabilitation program focused on improving gait parameters and functional mobility. The study is designed as a randomized and controlled clinical trial, conducted on a group of patients diagnosed with stroke. The results obtained demonstrate the effectiveness of the proposed intervention, supported by the use of standardized, validated and relevant assessment tools for the research objectives. The conclusions of the study highlight the potential of fusing functional massage of the gastrocnemius muscle with neurodevelopmental treatment, as an effective option for reducing spasticity, optimizing gait and increasing functional mobility in stroke patients.

The originality of the study lies in the "merge" of functional gastrocnemius massage with neurodevelopmental treatment, a previously little-explored combination that brings a new and promising perspective in post-stroke recovery, focused on reducing spasticity and optimizing locomotor function.

The title effectively captures the core elements of the study; however, while informative, it is somewhat lengthy and includes a minor inconsistency. Throughout the article, the term "functional massage" is consistently used, whereas the title refers to "function massage." It is unclear whether this variation is intentional or a typographical oversight, but it introduces a degree of ambiguity that could be confusing for the reader.

While the introduction reflects a comprehensive understanding of the clinical dimensions of the pathology and the corresponding therapeutic approaches, it transitions too quickly from a general presentation of treatment methods to highlighting functional massage, without providing a clear transition or a convincing argument regarding the effectiveness of this technique in a neurological context. Although the authors propose functional massage as an effective intervention for reducing spasticity and indicate a promising direction for its merge with neurodevelopmental therapy (NDT), the theoretical foundation remains insufficiently supported. The paper would benefit from a strengthening of the scientific framework by including relevant studies from the specialized literature and by a clearer delimitation of the investigated techniques, which would increase the validity and impact of the conclusions formulated.

Also, the authors don't clearly identify how the study relates to previous published research.

The Methods section offers a thorough overview of participant demographics, inclusion and exclusion criteria, data collection instruments, and statistical procedures. The statistical techniques implemented are appropriate for the nature of the data; even so, there remains room for improvement within this section. In the study period is stated as May–November 2024, and the intervention consisted of twice-weekly therapy sessions for six weeks. It would be useful to clarify the exact time frame: whether each participant received treatment for 6 weeks within this extended period (May–November), or whether the stated period reflects the total duration of the intervention for all participants. This information would help to better understand the organization and delivery of the intervention.

The discussion section accurately reflects the results obtained, with the findings providing strong support for the study’s primary objectives. The manuscript offers a valuable contribution to the stroke rehabilitation literature by shedding light on a relatively underexplored therapeutic approach. Even so, subtle insights can be better appreciated, such as the approach to spasticity which is treated in a relatively general way, with limited emphasis on its manifestations in the lower limb, particularly the foot. This limited focus somewhat diminishes the clarity and specificity of the analysis in relation to the study’s stated objectives. It may be beneficial for the authors to more clearly elaborate on the segmental aspects of spasticity, in order to better support the intervention’s effectiveness on the targeted region.

In addition, the paragraph beginning with "Spasticity, a common consequence of stroke, negatively affects functional characteristics of individuals such as walking, personal care, mobility, and transfer" until the section "Parikh et al. [32] showed that manual therapy—specifically myofascial release—can significantly reduce spasticity and increase joint mobility in stroke patients." contains noticeable redundancy, particularly in the repeated use of the term "spasticity." This excessive repetition makes the text harder to read giving the impression of a hurried or underdeveloped exposition of ideas. The authors are encouraged to revise this section to make the ideas clearer and improve the overall flow of the text.

The conclusion is generally well-aligned with the study’s findings, effectively underscoring the value of promoting a thoughtfully designed and innovative therapeutic approach. It highlights the strengths of the research while also maintaining a balanced perspective by acknowledging its limitations, thereby contributing to the credibility and relevance of the work.

Please check out the "doi" from Reference nr. 15- "Mostafa DE, Olama KA, Aly MG. Effect of instrument-assisted soft tissue mobilization on hamstring flexibility in children with diplegic cerebral palsy. Egypt J Hosp Med.2022;89(1):4842–7. doi:10.21608/ejhm.2022.242276." It seems to direct the reader to a source other than the one indicated.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Lect. Phd. PT. Eva ILIE

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PLoS One. 2025 Sep 24;20(9):e0332308. doi: 10.1371/journal.pone.0332308.r002

Author response to Decision Letter 1

11 Jul 2025

Reviewer #1:

Dear Reviewer,

Thank you very much for your valuable and constructive comments. They have helped us improve the transparency and scientific rigor of our manuscript. Below we provide point-by-point responses describing the changes made to the text.

1. Sample size and power analysis details

Reviewer comment:

“Based on an expected effect size of 1 ... insufficient information. What were the precise differences sought with standard deviations, effect sizes, etc.? ... These calculations should be checked against a more standard clinical trials sample size software ...”

Response:

Thank you for this important observation. We have now added detailed information about the sample size calculation to the Methods section. In the reference study, the mean change in the treatment group was 0.877 ± 0.799 (mean±SD), while in the control group it was -0.279 ± 0.729 (mean±SD). Based on these data, the calculated Cohen’s d effect size was approximately 1.51. Using G*Power with 95% power (power = 0.95) and a 5% significance level (α = 0.05), the estimated required sample size was 11 participants per group. To account for an anticipated dropout rate of approximately 25%, we planned to recruit additional participants. The study was ultimately completed with a total of 28 participants.

This clarification has been added to the Sample Size Calculation subsection of the Methods.

2. Parametric vs. non-parametric tests and normality assumption

Reviewer comment:

“The Statistical Analysis section refers to normal tests. However, the Tables presented look to be done non parametrically. If normality was assumed ...”

Response:

Thank you for pointing this out. We performed normality testing (Shapiro–Wilk) on our data and found that the assumptions for parametric tests were not satisfied. Therefore, non-parametric tests were used throughout the analysis. This choice is now clearly described in the Statistical Analysis section.

3. Multiple comparisons adjustment

Reviewer comment:

“Tables 2 to 4 show many statistical comparisons ... p-value adjustment for multiple comparisons should be examined ...”

Response:

We appreciate this comment. In our study, the main comparisons involved two independent groups. Since there were no multiple groups or multiple factors tested simultaneously, corrections such as Bonferroni adjustment were not deemed necessary.

Reviewer #2:

Dear Reviewer,

Thank you for your detailed review and constructive feedback on our study. Below, we provide our point-by-point responses to each of your comments:

1. Reviewer comment:

It would be useful to include some important demographic details in this section, such as gender distribution, stroke etiology (ischemic/hemorrhagic), and affected side (right/left).

Response:

The requested information has been provided in Table 1.

2. Reviewer comment:

However, some expressions (for example: “the therapist gently pulls the arm and trunk backwards…”) need clarification in terms of anatomy and biomechanics.

Response:

The noted ambiguity has been resolved, and the text has been revised for clarity.

3. Reviewer comment:

The extent to which the procedure was effective in terms of blinding (e.g., whether participants guessed their group) is not specified.

Response:

It has been clarified that the technique applied to patients was presented as a therapeutic approach, and no participant realized they were receiving a sham procedure.

4. Reviewer comment:

More information on session length and degree of individualization in content for NDT would be helpful.

Response:

The NDT procedure has been described in detail.

5. Reviewer comment:

It is not stated how many different assessors made the assessments and whether the assessors were blinded.

Response:

No blinding was performed. The study was designed and conducted as a randomized controlled trial, and all assessments were carried out by a single researcher.

6. Reviewer comment:

It would have been appropriate to refer to the validity and reliability information of the device.

Response:

Several reference articles regarding the use of the device in stroke patients have been provided.

7. Reviewer comment:

Taking the effect size as 1 is a very high assumption. It should be stated which source or preliminary study this value is based on.

Response:

In the reference study, the mean (±SD) changes were reported as 0.877 ± 0.799 in the treatment group and -0.279 ± 0.729 in the control group. Based on these data, the calculated Cohen’s d effect size was approximately 1.51. Using G*Power with 95% power (power = 0.95) and a 5% significance level (α = 0.05), the estimated required sample size was 11 participants per group. To account for an anticipated ~25% dropout rate, we planned to recruit 14 participants per group. The study was ultimately completed with a total of 28 participants.

8. Reviewer comment:

Sentence structures should be simplified; especially the part explaining the GFM application should be written in clearer and more technical terms.

Response:

Revisions have been made to address these ambiguities and improve clarity.

9. Reviewer comment:

A reference to the effect size used in the sample size calculation should be provided.

Response:

The reference used for the sample size calculation has been added to the manuscript.

10. Reviewer comment:

It should be stated whether the person(s) performing the spasticity assessment are the same person and whether blindness is ensured.

Response:

No blinding was performed. The study was designed and conducted as a randomized controlled trial, and all assessments were carried out by a single researcher.

11. Reviewer comment:

There are grammar and fluency problems in some sentences. Example: In the sentence “Participants in both groups had similar in terms of…” the expression “had similar” is used incompletely. The correct usage should be “were similar in terms of…”.

Response:

Thank you for pointing this out. The relevant sentences have been revised accordingly.

Reviewer #3:

Dear Reviewer,

Thank you very much for your thorough and constructive comments on our manuscript. We have carefully considered each point and revised the text accordingly. Below, we provide point-by-point responses to all of your suggestions:

1. Reviewer comment:

Consider adding "stroke patients" to the keywords for better indexing. The final sentence about long-term outcomes could be omitted in the abstract (due to word limits) and moved to the conclusion section of the main text.

Response:

The phrase “stroke patients” has been added to the keywords. However, to emphasize the importance of this aspect, the phrase “long-term outcomes” was intentionally retained in the abstract.

2. Reviewer comment:

The hypothesis (H1) should be rephrased in academic style, e.g., “It was hypothesized that functional massage would significantly improve...”.

Response:

The hypothesis statement has been revised as suggested to follow academic style.

3. Reviewer comment:

Massage description is written in an active, first-person tone (“The therapist stands…”). It should be revised into passive academic tone, e.g., “The therapist was positioned behind the patient…”. "10 GFM sham application" likely contains a typo — should be “10 minutes of sham GFM”. MMSE cut-off is listed as 23 — typically, 24 is used. Clarify with reference.

Response:

The relevant section has been rewritten in passive voice for academic tone. Information on the duration of GFM (10 minutes) has been added. Regarding MMSE, it was intended to indicate scores greater than 23, but was mistakenly written as “at least 23.” The text has been corrected to specify “at least 24.”

4. Reviewer comment:

Verify consistency between text and tables (e.g., changes in cadence or stride parameters).

Response:

Values for cadence and stride parameters have been checked for consistency between the text and the tables.

5. Reviewer comment:

Blinding details are not discussed. Was this single-blind or double-blind?

Response:

The relevant section has been reviewed, and the absence of blinding has been explicitly added as a limitation.

6. Reviewer comment:

Several minor spelling errors (e.g., “muslce” → “muscle”, “spacticity” → “spasticity”). Avoid direct instructions or first-person tone in the methods section.

Response:

All identified spelling errors have been corrected. The relevant sections have been revised to use passive academic language throughout.

Reviewer #4:

Dear Reviewer,

Thank you very much for your thorough and constructive review of our manuscript. We appreciate the time and effort you dedicated to providing detailed feedback. Below, we address each of your comments point by point.

1. Reviewer comment:

The manuscript aims to highlight the beneficial effects of functional massage applied in association with neurodevelopmental treatment...

Response:

Thank you for your overall positive evaluation and for recognizing the novelty and clinical value of our approach.

2. Reviewer comment:

Response:

Thank you for your careful attention. To eliminate this inconsistency and avoid confusion, we have revised the title to consistently use the phrase “functional massage.”

3. Reviewer comment:

While the introduction reflects a comprehensive understanding of the clinical dimensions... The theoretical foundation remains insufficiently supported...

Response:

We appreciate this valuable observation. We revised the Introduction section to more clearly and thoroughly explain the neurophysiological effects of functional massage. This enhancement improves the clarity and readability of the section and provides a stronger theoretical foundation for the study.

4. Reviewer comment:

It would be useful to clarify the exact time frame: whether each participant received treatment for 6 weeks within this extended period (May–November), or whether the stated period reflects the total duration of the intervention for all participants.

Response:

We have clarified that each participant received treatment for 6 weeks within the overall study period.

5. Reviewer comment:

The paragraph contains noticeable redundancy, particularly in the repeated use of the term "spasticity."

Response:

We have revised the paragraph to reduce repetition, shortened the content to improve clarity, and limited the use of the term “spasticity” for better readability.

6. Reviewer comment:

Please check out the "doi" from Reference nr. 15...

Response:

The incorrect DOI has been corrected to ensure accurate citation.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0332308.s006.docx^{(22.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0332308.r003

Decision Letter 1

Esedullah Akaras

12 Aug 2025

Dear Dr. SEKEROZ,

==============================

ACADEMIC EDITOR: After minor corrections, the article becomes suitable for publication.

==============================

Please submit your revised manuscript by Sep 26 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #1: One can see from the results section that the analyses showed significant changes in the EG group and mostly no significant changes in the CG subjects. The authors should thus tell the reader why no direct p-value was calculated or displayed in the Tables 2 to 4 comparing the pre to post changes in CG vs EG for each result. This could be a limitation of the study and require a larger future trial requiring a more adequate sample size. The Discussion section should be expanded accordingly.

Reviewer #2: I would like to inform you that I found the article you submitted to be scientifically sufficient. Your topic selection, methodological approach, and the contributions of your findings to the field were noteworthy. I believe your work will make valuable contributions to the literature. I thank you for your efforts and wish you continued success.

Reviewer #3: The revisions have been reviewed and the article has been deemed appropriate. I think it is suitable for publication. you.

Reviewer #4: I appreciate the authors' effort to respond rigorously and seriously to the reviewers' comments. All the issues raised have been adequately clarified, including strengthening the theoretical basis in the introduction, standardizing terminology, and detailing the duration of the intervention. The revised version of the manuscript brings significant improvements in terms of clarity, coherence, and scientific quality of the paper. I congratulate the authors for the careful way in which they integrated the feedback and for the obvious concern to perfect the study.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Ilie Eva

**********

PLoS One. 2025 Sep 24;20(9):e0332308. doi: 10.1371/journal.pone.0332308.r004

Author response to Decision Letter 2

19 Aug 2025

Response: We thank the reviewer for this valuable comment. In fact, p-values for both intra-group and inter-group comparisons were calculated and were already presented in Tables 2–4. To make this distinction clearer for readers, we have now added superscript letters a and b next to the p-values, where:

pᵃ: Intergroup comparison

pᵇ: Intragroup comparison

This explanation has been added below the tables to ensure that the distinction between intra-group and inter-group comparisons is clearly understood.

Response: We are grateful for your positive feedback and encouraging words. Your appreciation of our methodological approach and the potential contribution of our findings is highly motivating for our research team.

Reviewer #3: The revisions have been reviewed and the article has been deemed appropriate. I think it is suitable for publication. you.

Response: We thank you for your positive assessment and for recognizing the adequacy of the revised manuscript. Your supportive comments are greatly appreciated.

Response: We greatly appreciate your recognition of the improvements made in the revised manuscript. Your constructive feedback in the earlier review round was invaluable in enhancing the clarity, coherence, and scientific quality of our work.

Attachment

Submitted filename: Response_to_Reviewers_auresp_2.docx

pone.0332308.s007.docx^{(16.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0332308.r005

Decision Letter 2

Esedullah Akaras

29 Aug 2025

Effects of Gastrocnemius Functional Massage on Lower Extemity Spasticity, Spatio- Temporal Gait Variables and Fall Risk in Patients with Stroke: A Randomized Controlled Trial

PONE-D-25-03271R2

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PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: (No Response)

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The PLOS Data policy

Reviewer #1: (No Response)

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Reviewer #1: (No Response)

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Reviewer #1: No

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PLoS One. doi: 10.1371/journal.pone.0332308.r006

Acceptance letter

Esedullah Akaras

PONE-D-25-03271R2

PLOS ONE

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Data. CONSORT Checklist: The checklist provides detailed guidance on the essential methodological and reporting items addressed in the study.

(DOC)

pone.0332308.s001.doc^{(219.5KB, doc)}

(DOCX)

pone.0332308.s002.docx^{(19.3KB, docx)}

(DOCX)

pone.0332308.s003.docx^{(41.6KB, docx)}

The dataset includes all relevant variables necessary to replicate the results while ensuring participant confidentiality.

(XLSX)

pone.0332308.s004.xlsx^{(20KB, xlsx)}

Attachment

Submitted filename: Effects of Gastrocnemius Function Massage.docx

pone.0332308.s005.docx^{(13.4KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0332308.s006.docx^{(22.7KB, docx)}

Attachment

Submitted filename: Response_to_Reviewers_auresp_2.docx

pone.0332308.s007.docx^{(16.2KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

Effects of gastrocnemius functional massage on lower extemity spasticity, spatio- temporal gait variables and fall risk in patients with stroke: A randomized controlled trial

Aziz Dengiz

Serbay Sekeroz

Emre Baskan

Güzin Kara

Roles

Abstract

Aim

Methods

Results

Conclusion

Clinical trial registration

Introductıon

Methods

Study design

Participants

Procedure

Fig 1. Flowchart of the Study.

Gastrocnemius Function Massage (GFM)

Gastrocnemius sham application

Neurodevelopmental Treatment (Bobath therapy) (NDT)

Outcome measurements

Modified Asworth Scale (MAS)

Spatial Temporal Gait Analysis (Legsystm)

Timed up and Go Test (TUG) with legsystm

Sample size

Statistical analysis

Results

Table 1. Comparison of demographic and clinical values of stroke patients.

Table 2. Comparison of spasticity values of stroke patients.

Table 3. Comparison of basic gait parameters of stroke patients.

Table 4. Comparison of timed up and go test times of stroke patients.

Discussion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Esedullah Akaras

Roles

Author response to Decision Letter 1

Decision Letter 1

Esedullah Akaras

Roles

Author response to Decision Letter 2

Decision Letter 2

Esedullah Akaras

Roles

Acceptance letter

Esedullah Akaras

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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