Abstract
Real-time gait biofeedback is a promising rehabilitation strategy for improving biomechanical deficits in walking patterns of post-stroke individuals. Because wearable sensor technologies are creating avenues for novel applications of gait biofeedback, including use in tele-health, there is a need to evaluate the state of the current evidence regarding the effectiveness of biofeedback for post-stroke gait training. The objectives of this review are to: (1) evaluate the current state of biofeedback literature pertaining to post-stroke gait training; and (2) determine future research directions related to gait biofeedback in context of evolving technologies. Our overall goal was to determine whether gait biofeedback is effective at improving stroke gait deficits while also probing why and for whom gait biofeedback may be an efficacious treatment modality. Our literature review showed that the effects of gait biofeedback on post-stroke walking dysfunction are promising but are inconsistent in methodology and therefore results. We summarize sources of methodological heterogeneity in previous literature, such as inconsistencies in feedback target, feedback mode, dosage, practice structure, feedback structure, and patient characteristics. There is a need for larger-sample studies that directly compare different feedback parameters, employ more uniform experimental designs, and evaluate characteristics of potential responders. However, as these uncertainties in existing literature are resolved, the application of gait biofeedback has potential to extend neurorehabilitation clinicians' cues to individuals with post-stroke gait deficits during ambulation in clinical, home, and community settings, thereby increasing the quantity and quality of skilled repetitions during task-oriented stepping training. In addition to identifying gaps in previous research, we posit that future research directions should comprise an amalgam of mechanism-focused and clinical research studies, to develop evidence-informed decision-making guidelines for gait biofeedback strategies that are tailored to individual-specific gait and sensorimotor impairments. Wearable sensor technologies have the potential to transform gait biofeedback and provide greater access and wider array of options for clinicians while lowering rehabilitation costs. Novel sensing technologies will be particularly valuable for telehealth and home-based stepping exercise programs. In summary, gait biofeedback is a promising intervention strategy that can enhance efficacy of post-stroke gait rehabilitation in both clinical and tele-rehabilitation settings and warrants more in-depth research.
Highlights
Biofeedback is a process by which an external stimulus derived from previously covert physiological or motor performance data is provided to an individual in real time to induce selfmodification of a behavior [1,2,3,4,5,6]
Based on our analyses of the gaps in the previous research, we suggest that more favorable and conclusive evidence supporting gait biofeedback can be achieved if larger-sample studies are conducted to directly compare different feedback parameters, employ more uniformity in experimental design, and evaluate patient characteristics of potential responders
Large-sample RCTs are needed, especially for stroke survivors in more acute stages of recovery to compare the relative efficacy of biofeedback for different stages of recovery
Summary
Biofeedback is a process by which an external stimulus derived from previously covert physiological or motor performance data is provided to an individual in real time to induce selfmodification of a behavior [1,2,3,4,5,6]. Applications of biofeedback can be as disparate as cuing an individual with a tension headache to relax offending muscles through electromyographic (EMG) feedback and retraining standing balance through visual feedback regarding ongoing foot center of pressure data [3, 7]. Biofeedback can be used in locomotor rehabilitation to promote restitution of appropriate gait patterns [1]. The prevalence and impact of residual gait deficits after stroke positions post-stroke individuals as ideal candidates for gait biofeedback as a treatment modality, especially as an adjunct to other clinically-relevant and evidencesupported gait rehabilitation treatments such as high intensity locomotor training [15, 16]. Despite the compelling rationale for biofeedback as a gait training tool, its use is relatively uncommon in clinical practice
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