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Biofeedback for Gait Rehabilitation

Biofeedback techniques provide information to the patient in order to enhance appropriate responses, specifically gait movements in this chapter. Biofeedback techniques in publications include those based on EMG recordings of muscle activation or position or force sensors that provide feedback on joint motion or functional attributes such as weight-shifting.


Table 16: Biofeedback for Gait Rehabilitation

Author Year; Country
Research Design
Sample Size

Govil and Noohu 2013




Level 2


Population: 30 participants with incomplete SCI; randomized to 2 groups.

For Group 1: mean (SD) age = 38.73 (10.75); DOI= 17.87 (8.37).

For Group 2: mean (SD) age=38.03 (7.45); DOI = 16.93 (7.10).


Treatment: Group 1 received EMG biofeedback to the gluteus maximus muscle, as well as traditional rehabilitation and gait training for 5 days/wk for 4 wks. Group 2 received traditional rehabilitation and gait training for 5 days/wk for 4 wks.


Outcome Measures: Walking speed, step length, cadence, EMG.

1.    Significant differences were found between the two groups in:
– Walking velocity (m/s): Group 1 pre=0.12(0.11), post=0.27 (0.25); Group 2 pre=0.11(0.08), post=0.12(0.10); (p=0.043)
– Cadence: Group 1 pre=22.15(16.18), post=40.40(28.27); Group 2 pre=21.67 (20.71), post=22.04(21.71); (p=0.05).2.    Group 1 showed significant changes for EMG amplitude, step length, walking velocity and cadence pre and post.3.    Group 2 showed significant changes for EMG amplitude, walking velocity and step length, but not cadence pre and post.
Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data






Villiger et al. 2015


Longitudinal Study

Level 2

N= 23

Population: 9 SCI individuals- 5 males and 4 females; incomplete SCI; all AIS D; Lesion level between C4 to T12; mean age= 55.1 ± 15.8y; years post injury= 1-5y; 14 healthy individuals were in the control group – 8 males and 7 females; mean age= 47.1 ± 14.4y


Treatment: Patients underwent 4 weeks of intensive VR-augmented lower limb training. The patients with iSCI were trained with the VR movement tasks 16–20 times during the 4 weeks (4–5 × 45 min. per week). The training used a VR-augmented therapy system for lower limbs combining action observation, imagination and execution. Before and after the training period a structural volumetric 3D MRI data set was acquired in patients. Retention of the performance improvements was assessed in a 3–4 month follow-up session.


Outcome Measures: 10 MWT, Berg Balance Scale (BBS), Lower Extremity motor Score (LEMS), Spinal Cord Independence Measure (SCIM mobility)

1.     The intense VR-augmented training of limb control improved significantly balance, walking speed, ambulation, and muscle strength in patients.

2.     Retention of clinical improvements was confirmed by the 3–4 months follow-up.



Tamburella et al. 2013


Case Control

Level 3


Population: 12 participants with SCI; 6 in the vBFB group and 6 in control group (CTRL). vBFB group: mean (SD) age: 52 (11.74); 3M 3F. CTRL group: mean (SD) age: 53.5 (13.21); 3M 3F.


Treatment: 2 groups: vBFB and Rehab group (control). vFBF and CTRL groups underwent 8 wks of rehab 5 times/wk (CTRL: 60 minutes devoted to Rehab; vBFB: 40 minutes of rehab plus 20 of vBFB).


Outcome Measures: BBS; WISCI; 6MWT; 10MWT; TUG; balance performance and kinematic spatio-temporal gait parameters.

1.   Only the vBFB group experienced a significant improvement in balance and gait:
BBS: 26 (10.69) at baseline to 41(7.8) at end of intervention.
WISCI: 14.17(1.83) at baseline to 17.15(1.64) at end of intervention
6MWT: 193.18(68.08) at baseline to 259.64(82.84) at end of intervention2.   The improvement in balance and gait for the vBFB group was maintained at follow-up examinations.3.   vBFB participants experienced greater improvements than CTRL participants for all measures, except for one balance measure.

4.   vBFB treatment demonstrated a significantly higher level of effectiveness than conventional rehabilitation.





Wall et al. 2015



Level 4

N= 5

Population: 5 males; incomplete SCI; mean age= 58.6y; years post injury >1y


Treatment: An interrupted time series design with three pre-tests over three weeks, a post-test within one week of the intervention, and a four-week follow up. Intervention consisted of one-hour sessions with varied games using the Nintendo Wii Fit twice per week for seven weeks. Survey data was also collected at post-test.


Outcome Measures: Gait speed, Timed up and Go (TUG), Forward Functional Reach Test (FFRT), Lateral Functional Reach Test (LFRT), RAND SF-36

1.     There were statistically significant changes found in gait speed and functional reach.

2.     The changes were also maintained at the four-week follow up post-test.

3.     Survey reports suggested improvements in balance, endurance, and mobility with daily tasks at home.


In the study by Govil & Noohu (2013), biofeedback was provided in the form of EMG from the gluteus maximus muscle. Participants (N=30) were randomized into 2 groups either receiving biofeedback and gait rehabilitation or just gait rehabilitation. Both groups significantly improved from baseline in EMG amplitude, walking velocity and step length but the group receiving biofeedback improved by more. The biofeedback group also had significantly higher walking cadence. In the Tamburella et al. (2013) study, the visual biofeedback group experienced significant improvement in balance and gait measures which were maintained at follow-up.

[su_spoiler title=”Effect Size Forest Plots of RCTs with Available Data” style=”fancy”][su_row]Click on the image to enlarge[/su_row]
[su_lightbox type=”image” src=”/wp-content/uploads/Forest_LLimb_Govil_2013.gif”][image_with_animation image_url=”/wp-content/uploads/Forest_LLimb_Govil_2013.gif” alt=”Effect size SMD forest plot for Govil & Noohu 2013, EMG biofeedback”][/su_lightbox]


There is level 2 evidence (1 low quality RCT) (Govil & Noohu 2013) that EMG biofeedback may improve gait outcomes in patients with SCI.

There is Level 2 evidence that lower limb training augmented by biofeedback of ankle and knee movements can improve gait, balance, and muscle strength (Villiger et al., 2015).

There is level 4 evidence that virtual games (i.e., Nintendo Wii Fit) can enhance gait speed and functional reach and that these gains can be maintained at a 4 week follow-up (Wall et al., 2015).

  • EMG Biofeedback may improve gait, balance, and lower limb muscle strength in incomplete SCI.