Introduction
Biofeedback (BFB) has been practiced in clinical settings since the 1970’s, and has become a commonly used treatment in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation. Normal regulation of muscle tone following a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. is disrupted by central neuronal damage, which can result in decreased muscle functioning. Although the patient may have some preserved central motor pathways that remain relatively unaffected, these pathways are often unused. Individuals may learn how to use these preserved pathways with the help of electromyographic biofeedback (EMG-BFB). The use of EMG-BFB as an effective means of treatment for upper and lower extremity hemiparesis has been studied, given that hemiparesis of the lower extremity can result in functional disability following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and can affect important aspects of daily living (i.e. feeding and dressing).
Patient/Family Information
Author: Jamie Bitensky, MSc.OT
What is biofeedback for the lower extremity?
Biofeedback (BFB) has been practiced in clinical settings since the 1970’s, and has become a commonly used treatment in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation. Normal regulation of muscle tone can be disrupted by central nerve damage caused by a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This can prevent your muscles from functioning adequately. With the help of electromyographic biofeedback (EMG-BFB), you can get feedback concerning when your muscles are tense or relaxed. Electromyography or EMG is when a set of electrodes is placed on the skin over the chosen muscle or muscle group to detect the electrical signals that occur when a muscle is tense or contracted. This electrical signal will provide you with visual or auditory feedback on whether or not your muscle is contracting and the amount of force in the contraction.
Does it work for stroke?
Research studies have shown that biofeedback of the lower extremity can lead to improvements in the ability to walk, move your lower extremity to their full range, as well as improve the quality of lower extremity movements while walking. This intervention may also improve the ability to walk in a more natural, functional setting, such as on a sidewalk or street. However, these improvements do not seem to impact performance in daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
or the muscle stiffness in your lower extremity that is commonly associated with a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. These studies did not mention if there are any adverse or harmful effects of biofeedback for the lower extremity in clients who have experienced a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., such that this therapy seems to be safe.
Who provides the treatment?
Biofeedback for the lower extremity is typically performed by a physiotherapist. Most rehabilitation centers and private clinics are equipped with EMG equipment.
Clinician Information
Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Ten RCTs have investigated the efficacy of biofeedback in the lower extremity as a treatment intervention post-stroke. Specifically, biofeedback in the lower extremity has been examined in relation to gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery, range of motion (ROM), performance of activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living (ADLs), functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
, dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength, spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, and postural control. In eight of nine randomized controlled trials there were significant differences found for most of these outcome measures in favour of biofeedback therapy.
Results Table
View results table
Outcomes
Activities of daily living (ADL)
Not effective
1B
One high quality study investigated the relationship between biofeedback interventions and the ability to perform activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. post-stroke (Intiso et al. 1994). Using the Barthel Index as a measure of ADL performance, this study found no significant differences between groups. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on ADL, as assessed by the Functional Independence Measure (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that biofeedback interventions in the lower extremity are not effective in the recovery of functional performance in activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. post-stroke.
Dorsiflexion strength
Effective
1b
Two RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. have investigated the efficacy of biofeedback interventions for improving dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength post-stroke. One high quality study (Burnside et al. 1982) found a significant difference between groups, suggesting that biofeedback interventions in the lower extremity help to improve dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength post-stroke. One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Basmajian et al. 1975) also tested strength of dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
and observed significant differences between groups.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength can be improved as a result of biofeedback treatment in the upper extremity post-stroke.
Functional ambulation
Effective
1b
Two RCT studies investigated the relationship between biofeedback interventions and functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
post-stroke. One fair quality study (Mandel et al. 1990) found that walking speeds increased more rapidly for patients treated with a combination of biofeedback and conventional physical therapy. One high quality study (Intiso et al. 1994) also noted a significant improvement in walking ability for those who received biofeedback treatment. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
, as assessed by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories and walking speed (Heller et al. 2005). There were significant improvements for both groups on these assessments however no observed differences between the treatment and control group.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that biofeedback therapy in the lower extremity improves functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
post-stroke.
Two high quality RCTs investigated the use of biofeedback treatment in the lower extremity for enhancing gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery post stroke and noted significant differences between groups. Both Morris et al.(1992) and Burnside et al. (1982) found gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery was significantly improved for those who received biofeedback interventions. A high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Cozean et al. 1988) found greatest gains in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
cycle and stride length for the participants that had been exposed to biofeedback treatments in combination with functional electrical stimulation (FES) therapy. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
pattern, as assessed by the gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
spatiotemporal parameter using the Vicon© system (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.
Conclusion: There is strong evidence from three high quality RCTs (Level 1a) that biofeedback improves gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery post-stroke.
Postural control
Effective
2a
One fair quality study (Engardt et al. 1993) investigated the effect of biofeedback interventions for improving postural control post-stroke, using measures of sit-to-stand and rising to sit-down as primary outcomes. Significant improvements were noted in favour of biofeedback treatment. Another fair quality study (Wong et al. 1997) found that biofeedback improved the ability to maintain stance post-stroke. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on postural control, as assessed by the Postural Assessment Scale for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (PASS) (Heller et al. 2005). There were significant improvements for both groups on these assessments however no observed differences between the treatment and control group. One important finding was that the experimental group showed significant improvements in the duration of reception double stance on the paretic limb as compared to the control group.
Conclusion: There is limited (Level 2a) evidence to suggest that biofeedback interventions are effective in improving postural control post-stroke as noted in three fair quality studies.
Range of motion (ROM)
Effective
1A
Two high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. studies investigated the effect of biofeedback on range of motion in the lower extremity and all observed significant differences between groups. Burnside et al. (1982) noted significant improvements in range of motion for those who received biofeedback treatment. In a similar investigation, Bradley et al. (1998) found that active movement was significantly increased in patients that had received a combination of standard physiotherapy and biofeedback. One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Basmajian et al. 1975) found a significant improvement in the range of motion of dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
in favour of the treatment group that received combined biofeedback with standard physical therapy. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on motor recovery, as assessed by the Fugl-Meyer Motor Recovery Scale (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that biofeedback interventions improve range of motion (ROM) post-stroke.
Spasticity
Not effective
1B
One high quality study (Intiso et al. 1994) investigated the relationship between biofeedback interventions in the lower extremity and spasticity post-stroke. While the primary measure used to assess spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was the Ashworth Scale, no significant differences were noted between groups. Another recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. explored the use of biofeedback for standing balance training and its impact on spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as assessed by the Ashworth Scale (Heller et al. 2005). There were no significant improvements for both groups, as well as no observed differences between the treatment and control group.
Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
is not improved as a result of biofeedback interventions in the lower extremity.
References
Basmajian JV, Kukulka CG, Narayan MG, Takebe K. (1975). Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: effects on voluntary control and strength. Arch Phys Med Rehabil, 56, 231-236.
Bradley L, Hart BB, Mandana S, Flowers K, Riches M, Sanderson P. (1998). Electromyographic biofeedback for gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Clin Rehabil, 12, 11-22.
Burnside IG, Tobias HS, Bursill D. (1982). Electromyographic feedback in the remobilization of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients: a controlled trial. Arch Phys Med Rehabil, 63, 217-222.
Cozean CD, Pease WS, Hubbell SL. Biofeedback and functional electric stimulation in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation. Arch Phys Med Rehabil 1988; 69: 401-405
Engardt M, Ribbe T, Olsson E. (1993). Vertical ground reaction force feedback to enhance stroke patients’ symmetrical body-weight distribution while rising/sitting down. Scand J Rehabil Med, 25(1), 41-8.
Heller F., Beuret-Blanquart F., & Weber, J. (2005). [Postural biofeedback and locomotion reeducation in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients]. Ann Readapt Med Phys, 48(4), 187-195.
Intiso D, Santilli V, Grasso MG, Rossi R, Caruso I. (1994). Rehabilitation of walking with electromyographic biofeedback in foot-drop after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., 25, 1189-1192.
Mandel AR, Nymark JR, Balmer SJ, Grinnell DM, O’Riain MD. (1990). Electromyographic versus rhythmic positional biofeedback in computerized gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
retraining with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients. Arch Phys Med Rehabil 71, 649-654.
Morris ME, Matyas TA, Bach TM, Goldie PA. (1992). Electrogoniometric feedback: its effect on genu recurvatum in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Arch Phys Med Rehabil, 73, 1147-1154.
Wong AM, Lee MY, Kuo JK, Tang FT.(1997).The development and clinical evaluation of a standing biofeedback trainer. J Rehabil Res Dev, 34, 322-327.
