Effect of Task-Specific Training with and without Biofeedback on Balance and Risk of Falls in Chronic Ischemic Stroke Patients: A Narrative Review with Implications for Pakistan: Biofeedback on Balance and Risk of Falls in Chronic Ischemic Stroke Patients

Syed Ali  Behram Subazwari; Anil T.Jhon; Montiha Azeem; Layba Awais; Maryam Shabbir

doi:10.54393/pbmj.v9i4.1338

Authors

Syed Ali Behram Subazwari Department of Rehabilitation, Lincoln University College, Petaling Jaya, Malaysia
Anil T.Jhon Department of Rehabilitation, Lincoln University College, Petaling Jaya, Malaysia
Montiha Azeem University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan
Layba Awais University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan
Maryam Shabbir University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan

DOI:

https://doi.org/10.54393/pbmj.v9i4.1338

Keywords:

Ischemic Stroke, Balance Impairment, Task-Specific Training, Biofeedback, Fall Risk Assessment

Abstract

Balance deterioration is a contributing factor to fall risk and functional dependence and chronic ischemic stroke is responsible in long-term disability across the world. The aim of the study is to compare the effects of task-specific training (TST) versus no intervention on balance and fall risk in chronic ischemic stroke patients and to determine evidence gaps that could be of interest to low- and middle-income countries (LMICs) like Pakistan. PubMed, Scopus, and Google Scholar (2004-2025) were used as sources of a narrative review. Thirty-four studies (18 RCTs, 6 systematic reviews, 10 observational studies) met the inclusion criteria. Task-specific training (TST) was able to significantly enhance dynamic balance and functional mobility of chronic ischemic stroke patients. The addition of biofeedback to TST resulted in some further improvements in weight-bearing symmetry and postural (center of pressure) control, which were small-to-moderate in effect size. Fall incidence was only reported as an outcome in a minority of RCTs (4 out of 18). TST is a balance impairment rehabilitation method that is cost-effective and effective in chronic stroke. Biofeedback has some marginal biomechanical benefits, but the cost-efficacy of LMIC-based trials requires high quality to determine its cost-effectiveness in preventing falls.

References

Alwhaibi RM, Mahmoud NF, Zakaria HM, Badawy WM, Elzanaty MY, Ragab WM et al. A Comparative Study on the Effect of Task-Specific Training on Right Versus Left Chronic Stroke Patients. International Journal of Environmental Research and Public Health. 2020 Nov; 17(21): 7950. doi: 10.3390/ijerph17217950. DOI: https://doi.org/10.3390/ijerph17217950

Teasell R, Salbach NM, Foley N, Mountain A, Cameron JI, Jong AD et al. Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation Following Stroke. Part One: Rehabilitation and Recovery Following Stroke; Update 2019. International Journal of Stroke. 2020 Oct; 15(7): 763-88. doi: 10.1177/1747493019897843. DOI: https://doi.org/10.1177/1747493019897843

Gamble K, Chiu A, Peiris C. Core Stability Exercises in Addition to Usual Care Physiotherapy Improve Stability and Balance After Stroke: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation. 2021 Apr; 102(4): 762-75. doi: 10.1016/j.apmr.2020.09.388. DOI: https://doi.org/10.1016/j.apmr.2020.09.388

Ahmed U, Karimi H, Amir S, Ahmed A. Effects of Intensive Multiplanar Trunk Training Coupled with Dual-Task Exercises on Balance, Mobility, and Fall Risk in Patients with Stroke: A Randomized Controlled Trial. Journal of International Medical Research. 2021 Nov; 49(11): 03000605211059413. doi: 10.1177/03000605211059413. DOI: https://doi.org/10.1177/03000605211059413

Sharma B, Gaur P, Kadian P. Effect of Tetra-Ataxiometric Posturography Programs (Tetrax) on Stroke Patients with Impaired Standing Balance. Salt Journal of Scientific Research in Healthcare. 2022; 2(1): 20-30. doi: 10.56735/saltjsrh.ms2202012030. DOI: https://doi.org/10.56735/saltjsrh.ms2202012030

Alrasheed RA, Alanazi SF, Almutairi RO, Alshibani RM, Daghriri RI, Alshammari MM et al. Brain Stroke: Physical Therapy and Rehabilitation Techniques-An Updated Review. Egyptian Journal of Chemistry. 2024 Dec; 67(13): 2245-57. doi: 10.21608/ejchem.2025.344348.10982. DOI: https://doi.org/10.21608/ejchem.2025.344348.10982

Teodoro J, Fernandes S, Castro C, Fernandes JB. Current Trends in Gait Rehabilitation for Stroke Survivors: A Scoping Review of Randomized Controlled Trials. Journal of Clinical Medicine. 2024 Feb; 13(5): 1358. doi: 10.3390/jcm13051358. DOI: https://doi.org/10.3390/jcm13051358

Krohn M, Rintala A, Immonen J, Sjögren T. The Effectiveness of Therapeutic Exercise Interventions with Virtual Reality on Balance and Walking Among Persons with Chronic Stroke: Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials. Journal of Medical Internet Research. 2024 Dec; 26: e59136. doi: 10.2196/59136. DOI: https://doi.org/10.2196/59136

Cao J, Hu P, Li L, Dai F, Jin Y. Improving Post-Stroke Cognitive Impairment via Cognitive and Motor Dual Task Gait Training: Potential Mechanisms and Clinical Value. Neuropsychiatric Disease and Treatment. 2025 Dec: 2559-73. doi: 10.2147/NDT.S562404. DOI: https://doi.org/10.2147/NDT.S562404

Reddy KJ. Motor Rehabilitation and Biofeedback. In Innovations in Neurocognitive Rehabilitation: Harnessing Technology for Effective Therapy. Cham: Springer Nature Switzerland. 2025 Apr: 231-266. doi: 10.1007/978-3-031-88117-6_11. DOI: https://doi.org/10.1007/978-3-031-88117-6_11

Li N, Jin Q, Zhang Y, Zhang L, Peng X. Surface Electromyographic Biofeedback Versus Neuromuscular Electrical Stimulation for Post-Stroke Dysphagia: A Systematic Review and Network Meta-Analysis. Frontiers in Neurology. 2025 Oct; 16: 1649961. doi: 10.3389/fneur.2025.1649961. DOI: https://doi.org/10.3389/fneur.2025.1649961

Tian MY, Lee MH, Kim JH, Kim MK. Effectiveness of Virtual Reality Therapy on Static Postural Control and Dynamic Balance in Stroke Patients: Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials. Medicina. 2025 Dec; 62(1): 90. doi: 10.3390/medicina62010090. DOI: https://doi.org/10.3390/medicina62010090

Barbosa E, Gulela B, Taimo MA, Lopes DM, Offorjebe OA, Risko N. A Systematic Review of the Cost-Effectiveness of Emergency Interventions for Stroke in Low-and Middle-Income Countries. African Journal of Emergency Medicine. 2020 Jan; 10: S90-4. doi: 10.1016/j.afjem.2020.05.009. DOI: https://doi.org/10.1016/j.afjem.2020.05.009

Morelli N and Morelli H. Dual Task Training Effects on Gait and Balance Outcomes in Multiple Sclerosis: A Systematic Review. Multiple Sclerosis and Related Disorders. 2021 Apr; 49: 102794. doi: 10.1016/j.msard.2021.102794. DOI: https://doi.org/10.1016/j.msard.2021.102794

Kim KH and Jang SH. Effects of Task-Specific Training After Cognitive Sensorimotor Exercise on Proprioception, Spasticity, and Gait Speed in Stroke Patients: A Randomized Controlled Study. Medicina. 2021 Oct; 57(10): 1098. doi: 10.3390/medicina57101098. DOI: https://doi.org/10.3390/medicina57101098

Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients with Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. Journal of the American Medical Association. 2021 Jan; 325(3): 234-43.

Wu S and Liu M. Global Burden of Stroke: Dynamic Estimates to Inform Action. The Lancet Neurology. 2024 Oct; 23(10): 952-3. doi: 10.1016/S1474-4422(24)00363-6. DOI: https://doi.org/10.1016/S1474-4422(24)00363-6

Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun; 47(6): e98-169. doi: 10.1161/STR.0000000000000098. DOI: https://doi.org/10.1161/STR.0000000000000098

Dean CM, Rissel C, Sharkey M, Sherrington C, Cumming RG, Barker RN et al. Exercise Intervention to Prevent Falls and Enhance Mobility in Community Dwellers After Stroke: A Protocol for a Randomized Controlled Trial. BioMed Central Neurology. 2009 Jul; 9(1): 38. doi: 10.1186/1471-2377-9-38. DOI: https://doi.org/10.1186/1471-2377-9-38

Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Cote R. A Task-Oriented Intervention Enhances Walking Distance and Speed in the First Year Post Stroke: A Randomized Controlled Trial. Clinical Rehabilitation. 2004 Aug; 18(5): 509-19. doi: 10.1191/0269215504cr763oa. DOI: https://doi.org/10.1191/0269215504cr763oa

Globas C, Becker C, Cerny J, Lam JM, Lindemann U, Forrester LW et al. Chronic Stroke Survivors Benefit from High-Intensity Aerobic Treadmill Exercise: A Randomized Controlled Trial. Neurorehabilitation And Neural Repair. 2012 Jan; 26(1): 85-95. doi: 10.1177/1545968311418675. DOI: https://doi.org/10.1177/1545968311418675

Kim HS, Lee S, Kim JH. Real-World Evidence versus Randomized Controlled Trial: Clinical Research Based on Electronic Medical Records. Journal of Korean Medical Science. 2018 Jun; 33(34): e213. doi: 10.3346/jkms.2018.33.e213. DOI: https://doi.org/10.3346/jkms.2018.33.e213

Bang DH and Cho HS. Effect of Body Awareness Training on Balance and Walking Ability in Chronic Stroke Patients: A Randomized Controlled Trial. Journal of Physical Therapy Science. 2016; 28(1): 198-201. doi: 10.1589/jpts.2016.198. DOI: https://doi.org/10.1589/jpts.2016.198

Bang YJ, Cho JY, Kim YH, Kim JW, Di Bartolomeo M, Ajani JA et al. Efficacy of Sequential Ipilimumab Monotherapy Versus Best Supportive Care for Unresectable Locally Advanced/Metastatic Gastric or Gastroesophageal Junction Cancer. Clinical Cancer Research. 2017 Oct; 23(19): 5671-8. doi: 10.1158/1078-0432.CCR-17-0025. DOI: https://doi.org/10.1158/1078-0432.CCR-17-0025

Segev-Jacubovski O, Herman T, Yogev-Seligmann G, Mirelman A, Giladi N, Hausdorff JM. The Interplay Between Gait, Falls, and Cognition: Can Cognitive Therapy Reduce Fall Risk? Expert Review of Neurotherapeutics. 2011 Jul; 11(7): 1057-75. doi: 10.1586/ern.11.69. DOI: https://doi.org/10.1586/ern.11.69

Subramanian SK, Lourenço CB, Chilingaryan G, Sveistrup H, Levin MF. Arm Motor Recovery Using a Virtual Reality Intervention in Chronic Stroke: Randomized Controlled Trial. Neurorehabilitation and Neural Repair. 2013 Jan; 27(1): 13-23. doi: 10.1177/1545968312449695. DOI: https://doi.org/10.1177/1545968312449695

Rao AR, Kumar S, Dhekale R, Krishnamurthy J, Mahajan S, Daptardar A et al. Timed Up and Go as A Predictor of Mortality in Older Indian Patients with Cancer: An Observational Study. Cancer Research, Statistics, and Treatment. 2022 Jan; 5(1): 75-82. doi: 10.4103/crst.crst_79_22. DOI: https://doi.org/10.4103/crst.crst_79_22

Zhang SL, Liu D, Yu DZ, Zhu YT, Xu WC, Tian E et al. Multisensory Exercise Improves Balance in People with Balance Disorders: A Systematic Review. Current Medical Science. 2021 Aug; 41(4): 635-48. doi: 10.1007/s11596-021-2417-z. DOI: https://doi.org/10.1007/s11596-021-2417-z

Kang J, Park KW, Palmerini T, Stone GW, Lee MS, Colombo A et al. Racial Differences in Ischemia/Bleeding Risk Trade-Off During Anti-Platelet Therapy: Individual Patient Level Landmark Meta-Analysis from Seven RCTs. Thrombosis and Hemosatasis. 2019 Jan; 119(01): 149-62. doi: 10.1055/s-0038-1676545. DOI: https://doi.org/10.1055/s-0038-1676545

Mehrholz J, Harvey LA, Thomas S, Elsner B. Is Body-Weight-Supported Treadmill Training or Robotic-Assisted Gait Training Superior to Overground Gait Training and Other Forms of Physiotherapy in People with Spinal Cord Injury? A Systematic Review. Spinal Cord. 2017 Aug; 55(8): 722-9. doi: 10.1038/sc.2017.31. DOI: https://doi.org/10.1038/sc.2017.31

Pollock A, St George B, Fenton M, Firkins L. Top 10 Research Priorities Relating to Life After Stroke–Consensus from Stroke Survivors, Caregivers, and Health Professionals. International Journal of Stroke. 2014 Apr; 9(3): 313-20. doi: 10.1111/j.1747-4949.2012.00942.x. DOI: https://doi.org/10.1111/j.1747-4949.2012.00942.x

Saposnik G. Virtual Reality in Stroke Rehabilitation. Inischemic Stroke Therapeutics: A Comprehensive Guide. Cham: Springer International Publishing. 2016: 225-233. doi: 10.1007/978-3-319-17750-2_22. DOI: https://doi.org/10.1007/978-3-319-17750-2_22

Kim H, Im S, Park JI, Kim Y, Sohn MK, Jee S. Improvement of Cognitive Function After Continuous Positive Airway Pressure Treatment for Subacute Stroke Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial. Brain Sciences. 2019 Sep; 9(10): 252. doi: 10.3390/brainsci9100252. DOI: https://doi.org/10.3390/brainsci9100252

Skvortsov DV, Kaurkin SN, Ivanova GE. Targeted Biofeedback Training to Improve Gait Parameters in Subacute Stroke Patients: A Single-Blind Randomized Controlled Trial. Sensors. 2024 Nov; 24(22): 7212. doi: 10.3390/s24227212. DOI: https://doi.org/10.3390/s24227212

Martino Cinnera A, Ciancarelli I, Marrano S, Palagiano M, Federici E et al. Sensor-Based Balance Training with Exergaming Feedback in Subjects with Chronic Stroke: A Pilot Randomized Controlled Trial. Brain Sciences. 2024 Sep; 14(9): 917. doi: 10.3390/brainsci14090917. DOI: https://doi.org/10.3390/brainsci14090917

Shen J, Gu X, Yao Y, Li L, Shi M, Li H et al. Effects of Virtual Reality–Based Exercise on Balance in Patients with Stroke: A Systematic Review And Meta-Analysis. American Journal of Physical Medicine and Rehabilitation. 2023 Apr; 102(4): 316-22. doi: 10.1097/PHM.0000000000002096. DOI: https://doi.org/10.1097/PHM.0000000000002096

Akhir A, Mustapa A, Manaf H. Effectiveness of Exergames on Balance and Gait Performance among Post-Stroke Patients: A Systematic Review. Malaysian Journal of Medicine and Health Sciences. 2022 Jun; 18.

Dong K, Meng S, Guo Z, Zhang R, Xu P, Yuan E et al. The Effects of Transcranial Direct Current Stimulation on Balance and Gait In Stroke Patients: A Systematic Review and Meta-Analysis. Frontiers in Neurology. 2021 May; 12: 650925. doi: 10.3389/fneur.2021.650925. DOI: https://doi.org/10.3389/fneur.2021.650925

Bishnoi A, Lee R, Hu Y, Mahoney JR, Hernandez ME. Effect of Treadmill Training Interventions on Spatiotemporal Gait Parameters in Older Adults with Neurological Disorders: Systematic Review and Meta-Analysis of Randomized Controlled Trials. International Journal of Environmental Research And Public Health. 2022 Feb; 19(5): 2824. doi: 10.3390/ijerph19052824. DOI: https://doi.org/10.3390/ijerph19052824

Kilinc S, Ali C, Doganer I, Yaksi E, Ozdemir F. Effects of Virtual Balance Training and Conservative Rehabilitation on Balance in Chronic Stroke Patients. Neurology Asia. 2023; 28(3). doi: 10.54029/2023kcw DOI: https://doi.org/10.54029/2023kcw

Shahid J, Kashif A, Shahid MK. A Comprehensive Review of Physical Therapy Interventions for Stroke Rehabilitation: Impairment-Based Approaches and Functional Goals. Brain Sciences. 2023 Apr; 13(5): 717. doi: 10.3390/brainsci13050717. DOI: https://doi.org/10.3390/brainsci13050717