Effectiveness of Visual Feedback During

Isokinetic Exercise
Hong ). Kim, BScfPT), MSc '
john F. Kramer, BSc(PE), MA, P h D 2

hysiotherapeutic a p
proaches often use sensory
information (eg., tactile,
proprioceptive, visual, and
auditory inputs) in an ef-
fort to improve a patient's voluntary
muscular control (6,8-9,10,16,22,90,
35,42). Augmented sensory feedback
has been found to facilitate motor
unit activation during the skill acqui-
sition phase of motor learning while
Downloaded from www.jospt.org by 157.50.102.224 on 11/17/19. For personal use only.
Although previous investigators have observed that knowledge of performance via visual
feedback tends to enhance performance during an isokinetic test, the time frame over which visual
feedback remains advantageous is unclear. The purpose of this study was to compare knee
extensor torques produced by visual feedback and no visual feedback groups on three occasions,
completed over a 2-week period, and at 4 weeks afier the third test. Healthy, sedentary subjects
were each randomly assigned to either a visual feedback or a no visual feedback group IN = 10
males and 10 females per group). Visual feedback consisted of viewing a computer monitor which
displayed the current and a target knee extension force. Torques produced by the visual feedback
group were consistently greater (p < 0.05) and more reliable than those produced by the no visual
feedback group. The effectiveness of visual feedback tended to decrease over the fist three
occasions, suggesting that visual feedback may not be as advantageous once a skill is well learned.

inhibiting undesired motor behavior Further research needs to examine the contribution of visual feedback to motor learning as well as
(14,16,26). Isokinetic testing with vi- retention and transfer of motor skills during more complex functional tasks.
sual feedback tends to produce Key Words: knee extension, resistive exercise, visual feedback
higher torques than does testing with
' Physical Therapist, Scott Physiotherapy Clinic, Surey, British Columbia, Canada
no feedback (2,7,12,17,2l). While
conflicting results have been re-
' Director, School of Physical Therapy, Faculty of Health Sciences, Elborn College, University of Western
Ontario. london. Ontario, Canada N6G 1Hl
ported at fast angular velocities, there
is general agreement that the positive
effects of visual feedback on torque feedback is advantageous on one oc- skill acquisition and neuromuscular
are more evident at slower velocities casion, does it remain equally advan- control (8). The extent to which
J Orthop Sports Phys Ther 1997.26:318-323.

(2,7,12,17,2l). This latter finding
may be attributable to the additional
time available for visual information
processing and subsequent central
nervous system response at slower
velocities (2,12,20).
Available studies (2,7,12,17,2l)
have tended to use repeated mea-
sures designs, with each subject being
tested under both visual feedback
and no feedback conditions. As a re-
sult, learning or carryover effects
from one condition to the other may
have confounded results, particularly
if subjects had a preference for one
condition over the other. In addition,
investigations have typically used only
one test occasion (2,7,12,17), leaving
open the question of whether the
effectiveness of visual feedback
changes over time. That is, if visual
tageous on subsequent occasions?
Testing protocols with visual
feedback have included knee exten-
sion and flexion cycles, using concen-
tric muscle actions (2,12,17), eccen-
tric muscle actions (21), and
continuous concentriceccentric mus-
cle action cycles during knee exten-
sion (7). To the best of our knowl-
edge, the effects of visual feedback
during tests using isolated move-
ments and muscle actions have not
been reported. Whether visual feed-
back might differently affect isolated
or reciprocal movements (ie., knee
extension or knee flexion) and mus-
cle actions (ie., concentric or eccen-
tric) is unclear.
Visual feedback, through infor-
mation processing and additional
sensory input, is thought to facilitate
training with visual feedback leads to
longterm improvement in a skill and
is transferable to performance with-
out feedback is unclear. The perfor-
mance of a motor skill and it5 trans-
ferability to similar skills can be
assessed by using a similar skill after
an intervening period of no expo-
sure. The question of transferability,
or retainability of isokinetic move-
ment skills, has not been addressed
in earlier studies.
The primary purpose of the
present study was to compare knee
extensor peak torques during visual
feedback and no feedback conditions
on three test occasions completed
over a 2-week period. The secondary
purpose was to compare the visual
feedback and no visual feedback
groups during a separate test com-

Volume 26 Number 6 December 1997 JOSPT


Gender Variable
Males Age (years)
Height (m)
Mass (kg)
Females Age (years)
Height (m)
Mass (kg)
TABLE 1. Descriptive information tor subjects (N = 10 per cell) in the no visual i d b a c k and visual i d h a c k
groups (means and standard deviations).
pleted without visual feedback after 4
weeks without exposure to isokinetic
testing (retention test).
METHODS
Subjects
Forty young healthy subjects (20
males and 20 females), ranging in
age from 21 to 32 years, gave in-
formed consent to testing (Table 1).
Downloaded from www.jospt.org by 157.50.102.224 on 11/17/19. For personal use only.
They reported no known pathology
that might affect performance, only
occasional involvement in recre-
Facilitatory effects of
visual feedback may
be partially attributed
J Orthop Sports Phys Ther 1997.26:318-323.
to the '~sychological
carryover effect."
ational activities, and no previous ex-
perience using a computerized dyna-
mometer. All subjects had normal or
corrected-to-normal vision with lenses
and reported right leg dominance
(the leg used to kick a ball).
Test Procedures
The subjects completed the first
three tests within 2 weeks, with a
minimum of 2 days between tests.
Four weeks after the third test, they
were retested. On the first occasion,
subject. were randomly assigned to
JOSFT V o l m e 26 Number 6 December 1997
No Visual Feedback Visual Feedback
X SD X SD
28.6 4.2 29.4
1.76 11.4 1.74
68.3 14.0 73.5
27.1 2.1 27.4
1.65 10.4 1.63
52.7 9.2 54.8
one of two groups: 1) visual feedback
or 2) no visual feedback. All test..
were completed with subject.. seated
on a computerized dynamometer
(Kinetic Communicator 500H, Chat-
tecx Corporation, Hixson, TN), their
back against a backrest oriented 8.5"
above the horizontal and their hips
at 85" of flexion. A seatbelt oriented
diagonally over the pelvis secured it
to the test table during knee exten-
sion efforts. Subject.. were allowed to
grasp either the seatbelt or the test
table during testing (25). Their prefer-
ence was noted and they were required
to do the same throughout all testing.
During practice and testing, the
computer monitor was placed directly
in front of the subjects at eye level
and about 1.8 m away. The monitor
was rotated so that subjects in the
visual feedback group viewed the
screen (28 X 21 cm), while subjects
in the no visual feedback group
viewed the back of the monitor.
Practice and testing were con-
fined to the knee extensors, using
isolated concentric and eccentric
muscle actions through the range
85 to 5" of flexion, at an angular ve-
locity of 45"/sec. Dynamometer acti-
vation or threshold force was set at
midpoint. Each test occasion in-
cluded a separate set of three repeti-
tions of concentric and a separate set
of three repetitions of eccentric mus-
cle actions. The subjects were given a
15-second rest between repetitions
and a 2-minute rest between muscle
action sets. The sequence of eccen-
tric and concentric muscle actions
was randomly assigned for each s u b
ject on each test occasion.
- - .--.". .-- --.. - R- E S E A R C H STUDY
3.4
8.8
8.8
4.1
9.9
9.5
Ditutioa of Movement of Ught B a m .ad Kaec Ertndon
FIGURE 1. Force pattern during visual feedback-
eccentric muscle action. The target pattern remained
on the screen, while the subject attempted to keep the
current force pattern above the target pattern.
Following verbal explanation of
the test procedure, the subjects prac-
ticed two submaximal efforts and
then completed two maximal efforts
using the assigned feedback condi-
tion and muscle action. No verbal
feedback was provided during the
test. The highest of these two maxi-
mal efforts was retained on the com-
puter screen and provided the initial
target force pattern for the visual
feedback group (Figure 1). The com-
puter screen displayed instantaneous
force in the form of a continuous
moving light beam (Figure 1). The
visual feedback subjects were in-
structed that the objective during
testing was to make the current or
real-time beam display, which moved
across the computer screen from
right to left during eccentric muscle
actions or left to right during con-
centric muscle actions, exceed their
previous "best" force pattern, which
remained on the monitor during that
test. This skill was described verbally
and demonstrated by the tester man-
ually moving the dynamometer arm.
Subjects initially practiced using s u b
maximal efforts, during which they
were readily able to produce forces
which deflected the current beam
display above and below the target
force pattern. The subjects in the no
visual feedback group were instructed
to push (concentric) or resist (eccen-
tric) as hard as possible throughout
the movement.
 RESEARCH STUDY .- -" >. - -. - -

No Visual Feedback (N = 20) V i i l Feedback (N = 20)

--
500-
Test Muscle Action Musde Action
Concentric Eccentric Concentric Eccentric 280-
--

First occasion 0.74 0.82 0.84 0.94

2W-
Second occasion 0.81 0.88 0.92 0.98
Third occasion 0.91 0.95 0.96 0.97
z240-
Retention 0.76 0.86 0.91 0.96 2
W
5
TABLE 2. Within-occasion-bemn-repetition reliability coefficients on the first, the second, and the third Q
occasion, and the retention test. a
0
I- zoo-

Four weeks after the third test tween scores on the third occasion 1w -
occasion, the test procedure was and the retention test. Following a IW -
repeated, with the exception that vi- significant F ratio, a Newman-Keuls
sual feedback was not provided to test was used to compare selected 140 -
1
either group (retention test). All test- pairs of means. The 0.05 level was
ing was completed by the same tester, used to denote statistical significance 0 T
8 1 I

1 2 3
who used the same standardized in- throughout testing. OCCASlONS
structions that had been used with
FIGURE 2. Peak toques during visual feedback fVF)
the no visual feedback group during RESULTS and no visual feedback (NF) conditions. Data aver-
the initial three test occasions. aged over gender and repetitions (N = 20). 1 =
Within-Occasion-Between-Repetition Standard deviation.
Data Analysis Reliability
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All peak torques were corrected
for the effects of gravity on the limb
segment and resistance pad. Between-
repetition reliability on each occasion
was determined using intraclass cor-
relation coefficients (ICC.,,) (4,36).
A five-way analysis of variance
(ANOVA) (two visual feedback condi-
tions X two genders X two muscle
actions X three occasions X three
J Orthop Sports Phys Ther 1997.26:318-323.
Between-repetition ICCs in- interactions (condition X occasion
creased on each of the initial three and occasion X muscle action), and
occasions, but decreased on the re- all four main effects were statistically
tention test-more so for the no vi- significant (p < 0.05) on the
sual feedback group than for the vi- ANOVA. Post hoc analysis of the con-
sual feedback group (Table 2). The dition X occasion X muscle action
visual feedback group demonstrated interaction (averaged over gender
higher ICCs than did the no visual and repetition) indicated that both
feedback group, and the ICCs for eccentric and concentric peak
eccentric muscle actions were higher torques for the no visual feedback

repetitions) was used to test for statis-
tically significant differences over the
three occasions (37). A second five-
way ANOVA (two visual feedback
conditions X two genders X two
muscle actions X two occasions X
three repetitions) was used to test for
statistically significant differences be-
than those for concentric actions. condition, as well as concentric peak
torques for the visual feedback
ANOVA for the Three Occasions group, were significantly higher on
each successive occasion (p < 0.01;
Table 3 presents peak torques for Figure 2). However, eccentric torques
all tests. One of the three three-way for the visual feedback group stabi-
interactions (condition X occasion X lized on the second occasion (first
muscle action), two of the six two-way occasion < second occasion and first

No Visual Feedback ( N = 20) Viswl Feedback (N = 20)

Concentric Eccentric Concentric Eccentric
Test
Male Female Male Female Male kmale Male Female
X SD X SD X SD X SD X SD X SD X SD X SD
First occasion 191 14 143 17 240 10 188 22 230 15 173 17 288 12 239 19
Second occasion 204 12 156 16 253 14 200 23 251 10 195 15 303 12 255 21
Third occasion 226 11 178 12 268 13 214 21 263 11 206 14 302 13 254 20
Retention 196 16 142 18 256 26 196 24 240 31 186 31 296 28 249 22

TABLE 3. Means and standard deviations ior peak torques (Nm) on three occasions and the retention test. Scores averaged over the three repetitions on each test
(N = 10 subjects per celll.

320 Volume 26 Number 6 December 1997 JOSF'T


occasion < third occasion, P < 0.01;
-
but second occasion third occa-
sion, p > 0.05). Torques produced by
the visual feedback group were signif-
icantly greater than those for the no
visual feedback group during the re-
spective concentric and eccentric
muscle actions on each occasion
(p < 0.01).
On the condition X occasion
interaction, torques produced by the
visual feedback group stabilized on
the second occasion, while torques
produced by the no visual feedback
group were significantly higher on
each occasion (p < 0.05). On the
occasion X muscle action interaction,
torques produced during eccentric
muscle actions stabilized on the sec-
ond occasion, while torques pro-
duced during concentric muscle ac-
tions were significantly higher on
each occasion (p < 0.05).
Downloaded from www.jospt.org by 157.50.102.224 on 11/17/19. For personal use only.
ANOVA for the Retention Test
Two of the six two-way interac-
tions (condition X occasion and mus-
cle action X occasion) and all four
main effects were significant (P <
0.05) on the ANOVA. For the condi-
tion X occa..ion interaction (aver-
aged over gender, muscle action, and
J Orthop Sports Phys Ther 1997.26:318-323.
repetitions), peak torques for the no
visual feedback condition were signif-
icantly lower on the retention test
than on the third occasion (P <
0.01), whereas torques for the visual
feedback condition were similar (P >
0.05). For the muscle action X occa-
sion interaction (averaged over gen-
der, condition, and repetitions), peak
torques during concentric muscle
actions were significantly lower on
the retention test (p < 0.001),
whereas eccentric torques were simi-
lar (p > 0.05). Torques produced
using the visual feedback condition
were significantly greater than those
produced using the no visual feed-
back condition for both the condi-
tion X occasion interaction and the
condition main effect (p < 0.01).
JOSFT Volume 26. Number 6 December 1997
DISCUSSION
In agreement with previous studies
(2,12,17), the present study also found
enhanced knee extension torques with
visual feedback. Whereas previous stud-
ies reported torques produced using
visual feedback to be >12% higher
than those produced without visual
feedback, the present study observed
visual feedback to produce torques
ranging from 19% (on the first and
second occasions) to 14% (on the
third occasion) higher than the no
visual feedback condition. Although
there was a tendency for the visual
feedback group to be heavier than the
no visual feedback group, t tests (inde
pendent and nondirectional) indicated
no significant differences between the
two groups for males, females, or the
group as a whole (p > 0.05). Further-
more, the correlation between body
mass and peak torques was only 0.27
(Pearson product moment correlation;
p > 0.05), indicating a low relationship
between body mass and torques for
these subjects. For these reasons, we
attribute the diierence between
groups to the visual feedback. In the
present study, each subject participated
in only one condition, while in previ-
ous studies, the subjects completed
both visual feedback and no feedback
conditions. In addition, subjects in the
present study tended to be sedentary
(they exercised only sporadically and
less than two times per week) and may
better reflect the activity backgrounds
of patients typically seen by physical
therapists. The present study also com-
pared the responses of males and fe-
males and noted no significant differ-
ences in responses to visual feedback.
Previous studies have not exam-
ined between-repetition variation or
the effectiveness of visual feedback
over subsequent test occasions. Al-
though Kellis and Baltzopoulos (21)
reported test-retest reliability for 13 of
25 subjects for the no visual feedback
test, they did not compare reliability
coefficients for the visual feedback and
no visual feedback conditions. Reliabil-
ity for the visual feedback condition in
RESEARCH STUDY
the present study tended to be greater
than that for the no visual feedback
condition, suggesting greater consis
tency of performance with visual feed-
back. While torques for the no visual
feedback condition increased on each
successive occasion, eccentric torques
for the visual feedback condition stabi-
lized on the second occasion (Figure 2,
Table 3). Stabilization or saturation of
torque output with visual feedback may
be attributed to enhancement of m e
tor learning, which may be reflected in
a number of ways,including facilitation
of motor unit recruitment and/or pe-
ripheral reflex support (3,13,27,28,31,
32,40). The present results suggest that
visual feedback has a facilitatory effect
on motor learning, enabling skilled
movements to be learned more
quickly. However, the diminishing ef-
fectiveness of visual feedback over time
suggests that visual feedback is only
necessary for learning and may be less
important for the performance of well-
learned tasks (18,19,26,33,34,38,45-
47). Thus, patients in clinical settings
may not benefit as much from visual
feedback once the movement has been
repeatedly practiced and is well
learned.
These facilitatory effects of visual
feedback may be partially attributed to
the "psychological carryover effectn of
the visual feedback incentive system, as
described in classical conditioning t h e
ory (39). Our findings also support the
concept of "apria' knowledge" (15),
where performance is updated by kin-
esthetic and cutaneous information
obtained earlier. In the present study,
subjects receiving visual feedback may
have better learned to use additional
sensory inputs which guided the de-
sired movement (knee extension) dur-
ing retention testing when visual feed-
back was withdrawn. Thus, visual
feedback may be advantageous during
the early phase of learning (13,30,38,
42-44), where it serves to facilitate
neuromuscular control and to refine
motor skill.
After 4 weeks without exposure
to isokinetic exercise, the visual feed-
back group demonstrated only
32 1
 RESEARCH STUDY
slightly lower between-repetition reli-
ability coefficients and torques on the
retention test than on the third test
occasion. In contrast, on the reten-
tion test, the no visual feedback
group was characterized by signifi-
cantly lower between-repetition reli-
ability and torques than on the third
test occasion. These results suggest
greater variation and poorer retain-
ability of the knee extension skill in
the no visual feedback group. We
interpret these findings to suggest
that training with visual feedback
over the first three occasions pro-
duced more effective learning, lead-
ing to greater retention of the knee
extension skill.
In agreement with Carlson et al
(7), the present study found eccentric
muscle actions to be more responsive
to visual feedback. In addition to
torque saturation or stabilization on
the second occasion obsewed in the
Downloaded from www.jospt.org by 157.50.102.224 on 11/17/19. For personal use only.
present study (Figure 2), eccentric
muscle actions also demonstrated
higher between-repetition reliability
coefficients, particularly in the visual
feedback group (Table 2). Further-
more, reliability coefficients and
torques changed least between the
third test and the retention test during
eccentric muscle actions performed by
the visual feedback group. These re-
sults suggest that motor learning may
J Orthop Sports Phys Ther 1997.26:318-323.
occur more readily during eccentric
muscle actions, resulting in higher
torques and higher reliability. As a re-
sult, eccentric muscle actions per-
formed using visual feedback may be a
preferred means to learn a motor skill.
This suggestion, however, requires fur-
ther study.
In a recent review, Enoka (11)
concluded that eccentric muscle ac-
tions were characterized by unique
motor unit activation strategies com-
pared with isometric and concentric
muscle actions. In the present study,
visual feedback may have selectively
affected recruitment strategies during
eccentric muscle actions. Possible
mechanisms which might explain the
greater sensitivity of eccentric muscle
actions to visual feedback include:
322
I ) motor recruitment efficiency,
2) passive parallel elasticity of muscle ment skill obtained using visual
spindles, and 3) advantages of cross-
bridge kinetics. Eccentric muscle ac-
tions utilize more efficient recruit-
ment strategies, such as selective fast- Clinical Implications
twitch motor unit recruitment with a
lower motor unit requirement (1.22,
41). While spindle unloading occurs
during concentric muscle actions, the peak torque tends to be enhanced
stretched muscle spindle may provide compared to testing without visual
additional peripheral reflex support
during eccentric muscle actions, en-
abling faster modification of the de-
sired motor activity by producing re-
flexive compensation (3,5,19,23,24,
46). Energy expenditure and
mechanical work change proportion-
ally in concentric actions; however,
during eccentric muscle actions, net
mechanical advantages can be achieved stimulus, especially during the initial
with greater mechanical efficiency and
energy dissipation (12,23,24). When
the muscle fibers are lengthened dur-
ing an eccentric muscle action, the
actomyosin bonds might be disrupted
rather than undergo an ATPdepen-
dent detachment (12). These biome-
chanical advantages can be described
as the sarcomere "popping" theory,
which results from the unequal
strength characteristics of various sar-
comeres during an active ballistic
lengthening (23,24,29).Since isoki-
netic torques combine sewocontrolled
and voluntary muscle contraction, en-
hancement of eccentric torques with
visual feedback may be attributable to
improved motor unit recruitment
and/or peripheral reflex support (27,
28,30-32,34,40).
The present study was limited to
two specific motor skills, concentric
and eccentric knee extension, and
tested a relatively slow angular veloc-
ity (45"/sec) to maximize the oppor-
tunity for all subject. to interpret and
utilize the visual feedback informa-
tion. Further research is required to
examine different types of visual
feedback and their effectiveness dur-
ing more complex functional tasks,
such as walking and stairs activities,
its effectiveness with individuals hav-
ing different pathologies and the ex-
tent to which knee extension move-
feedback is retained over time and is
advantageous in functional tasks.
During isokinetic training/testing
using visual feedback, knee extensor
feedback for at least three test occa-
sions completed within a 2-week pe-
riod. As a result, knee extensor
torques determined with visual feed-
back should not be comparable with
those determined without visual feed-
back. In addition, visual feedback
may be advantageous in learning a
motor skill and as a strength training
phase of strength training. However,
the effectiveness of visual feedback
decreases with exposure to the crite-
rion task, particularly during eccen-
tric muscle actions.
CONCLUSIONS
I ) The visual feedback condition
was characterized by higher between-
repetition reliability than was the no
visual feedback condition, particularly
during eccentric muscle actions;
2) torques during visual feedback
tended to stabilize on the second occa-
sion, in particular, eccentric torques;
3) the effectiveness of visual feedback
decreased over time, particularly dur-
ing eccentric muscle actions; and
4) previous practice using visual feed-
back led to transfer of knee extension
skills after 4 weeks without training,
wherea. previous practice with no vi-
sual feedback was characterized by rela-
tively poor skill retention. JOSIT
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