Biofeedback for Post-stroke Gait Retraining: A Review of Current Evidence and Future Research Directions in the Context of Emerging Technologies

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.

Repurposing an EMG Biofeedback Device for Gait Rehabilitation: Development, Validity and Reliability

“…Although there have been over 1000 randomized clinical trials in stroke rehabilitation, to date, little translation to clinical practice has taken place [ 68 , 69 ]. Therefore, more research must be performed that translates laboratory-based results into applied rehabilitation settings, using wearable technologies such as the mTrigger system that are both cost-effective and commercially available [ 24 ]. Our short-term goals are to field test the mTrigger systems in stroke and other neurological gait conditions to assess the immediate effects on improving walking function and walking biomechanics.…”

“…The need for valid and reliable EMG BFB devices for clinical and home use was also noted in a recent review published in 2021 on the application of biofeedback for post-stroke gait retraining in the context of emerging technologies [ 24 ]. Despite the extant literature showing its effectiveness in improving functional outcomes [ 3 , 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ], EMG-BFB has been used almost exclusively within research studies and not as a clinical or field-based tool.…”

“…Despite the extant literature showing its effectiveness in improving functional outcomes [ 3 , 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ], EMG-BFB has been used almost exclusively within research studies and not as a clinical or field-based tool. One contributing factor has been the technological hurdles related to use outside the laboratory [ 24 ]. Laboratory-grade EMG systems are cumbersome, complex, and require significant setup preparation before the application of sensors (including the need for computer and cabling and syncing across devices), followed by the extensive post-processing of signals.…”

A Study of Biofeedback Gait Training in Cerebral Stroke Patients in the Early Recovery Phase with Stance Phase as Target Parameter

“…Biofeedback technology (BFB) is currently considered effective and promising for training walking function [1][2][3], including in patients after cerebral stroke [3]. The technology is based on capturing a physiological parameter and presenting it to the patient in a perceivable form, so that the subject can understand its changes and respond appropriately.…”

“…Another commonly used parameter is the EMG activity of muscles (mostly of the lower-leg triceps). Spatiotemporal, kinematic, and kinetic parameters are also used [3]. Spatiotemporal parameters are most often used to train step length on the paretic side [3].…”