Biofeedback – Lower Extremity

Evidence Reviewed as of before: 04-10-2011
Author(s): Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jeffrey Jutai, PhD Csych; Timothy Doherty, MD, PhD; Jamie Bitensky, MSc OT; Mark Speechley, PhD; Chelsea Hellings, BSc; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Biofeedback (BFB) has been practiced in clinical settings since the 1970’s, and has become a commonly used treatment in stroke rehabilitation. Normal regulation of muscle tone following a stroke 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 stroke 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 stroke rehabilitation. Normal regulation of muscle tone can be disrupted by central nerve damage caused by a stroke. 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 activities or the muscle stiffness in your lower extremity that is commonly associated with a stroke. 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 stroke, 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 (RCT) 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 gait recovery, range of motion (ROM), performance of activities of daily living (ADLs), functional ambulation, dorsiflexion strength, spasticity, 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

Only one high quality study investigated the relationship between biofeedback interventions and the ability to perform activities of daily living (ADL) 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 RCT 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 RCT and one fair quality RCT that biofeedback interventions in the lower extremity are not effective in the recovery of functional performance in activities of daily living (ADL) post-stroke.

Dorsiflexion strength
Effective
1b

Two RCT have investigated the efficacy of biofeedback interventions for improving dorsiflexion 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 dorsiflexion strength post-stroke. One fair quality RCT (Basmajian et al. 1975) also tested strength of dorsiflexion and observed significant differences between groups.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT that dorsiflexion 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 ambulation 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 RCT explored the use of biofeedback for standing balance training and its impact on functional ambulation, as assessed by the Functional Ambulation 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 RCT that biofeedback therapy in the lower extremity improves functional ambulation post-stroke.

Gait recovery
Effective
1a

Two high quality RCTs investigated the use of biofeedback treatment in the lower extremity for enhancing gait recovery post stroke and noted significant differences between groups. Both Morris et al.(1992) and Burnside et al. (1982) found gait recovery was significantly improved for those who received biofeedback interventions. A high quality RCT (Cozean et al. 1988) found greatest gains in gait 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 RCT explored the use of biofeedback for standing balance training and its impact on gait pattern, as assessed by the gait 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 gait 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 RCT explored the use of biofeedback for standing balance training and its impact on postural control, as assessed by the Postural Assessment Scale for Stroke (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 RCT 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 RCT (Basmajian et al. 1975) found a significant improvement in the range of motion of dorsiflexion in favour of the treatment group that received combined biofeedback with standard physical therapy. A recently published fair quality RCT 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 RCT 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 spasticity was the Ashworth Scale, no significant differences were noted between groups. Another recently published fair quality RCT explored the use of biofeedback for standing balance training and its impact on spasticity, 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 RCT and one fair quality RCT that spasticity 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 gait training after stroke. Clin Rehabil, 12, 11-22.

Burnside IG, Tobias HS, Bursill D. (1982). Electromyographic feedback in the remobilization of stroke patients: a controlled trial. Arch Phys Med Rehabil, 63, 217-222.

Cozean CD, Pease WS, Hubbell SL. Biofeedback and functional electric stimulation in stroke 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 stroke 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 stroke. Stroke, 25, 1189-1192.

Mandel AR, Nymark JR, Balmer SJ, Grinnell DM, O’Riain MD. (1990). Electromyographic versus rhythmic positional biofeedback in computerized gait retraining with stroke 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 stroke. 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.

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