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Topics in Stroke Rehabilitation

ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: https://www.tandfonline.com/loi/ytsr20

The Role of Biofeedback in Stroke Rehabilitation:


Past and Future Directions

Lonnie A. Nelson

To cite this article: Lonnie A. Nelson (2007) The Role of Biofeedback in Stroke Rehabilitation:
Past and Future Directions, Topics in Stroke Rehabilitation, 14:4, 59-66, DOI: 10.1310/tsr1404-59

To link to this article: https://doi.org/10.1310/tsr1404-59

Published online: 18 Dec 2014.

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Citing articles: 21 View citing articles

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The Role of Biofeedback in Stroke
Rehabilitation: Past and Future Directions
Lonnie A. Nelson

Biofeedback has been applied to many aspects of stroke rehabilitation, with mixed results. This is largely due to the varying
modalities, differences between study designs, and methods of measuring success and progress. How well biofeedback
works appears to be inversely related to the direct observability of the function about which information is being provided.
The more covert the function (e.g., swallowing muscle activity, attention, cortical functioning, etc.), the more helpful
biofeedback is likely to be. However, biofeedback in general can have a very positive impact, even through indirect means.
Improvements in self confidence, shifting of locus of control, and instantly being provided information regarding changes
in one’s physical functioning as a result of mental activity can be helpful in setting the tone for success in rehabilitation
more generally. Key words: acquired brain injury, attentional control, balance, biofeedback, cognitive rehabilitation, cortical
reorganization, gait, neurofeedback, neurotherapy, recovery of function, rehabilitation, stroke

S
troke incidence is approximately 158 per One benefit of using biofeedback in stroke reha-
100,000 and is a leading cause of disability bilitation is that it can give the patient and practi-
in the United States.1,2 There are close to 4.4 tioner access to information about physiological
million stroke survivors in the United States, and functioning in various domains that might other-
nearly 40% of these individuals have at least wise be too subtle to detect or too subjective to
moderate functional impairments, with 15%–30% accurately assess and consciously manipulate. The
having severe disabilities.3 Because of the hetero- current article is meant to serve as a brief overview
geneous manifestations of stroke, functional of the efficacy literature regarding the application
impairments resulting from ischemic or hemor- of biofeedback to various aspects of functioning in
rhagic events can vary widely. Common physical poststroke recovery.
sequelae include hemiparesis or hemiplegia,
incontinence, as well as dysphagia and dysarthria.4 Biofeedback Applications to Physical Recovery
Common cognitive sequelae of stroke include
aphasia, abulia, impairments of attention and Hemiparesis
memory, spatial neglect, personality changes, and
anosagnosia.2,5,6 However, there is good support An early application of biofeedback technology
for the notion that rehabilitation efforts can to stroke rehabilitation was in the domain of elec-
significantly impact the degree of disability that tromyographic (EMG) biofeedback for neuromus-
individuals experience in the weeks and months cular reeducation in individuals with hemiparesis.
following stroke. 7 Specifically, meta-analytic In this application of biofeedback, electrodes are
studies and systematic literature reviews have placed on specific muscles that are important in
revealed specific significant benefits in functional particular limb movements, and information
outcomes (e.g., FIMTM* scores) for physical
therapy,8 occupational therapy,9 and cognitive
rehabilitation.10 Lonnie A. Nelson, PhD, is an Affiliate Assistant Professor,
University of Washington, School of Medicine, Department of
Recent Ottawa Panel evidence-based clinical Psychiatry, Seattle, Washington, and Co-Director of Clinical
practice guidelines for poststroke rehabilitation in- Services, Neurobehavioral Health Services, Tucson, Arizona.
clude biofeedback as a positive recommendation
for management of several conditions poststroke.11
Top Stroke Rehabil 2007;14(4):59–66
© 2007 Thomas Land Publishers, Inc.
www.thomasland.com
*FIMTM is a trademark of Uniform Data System for Medical Rehabilita-
tion, a division of UB Foundation Activities, Inc. doi: 10.1310/tsr1404-59

59
60 TOPICS IN STROKE REHABILITATION/JULY-AUG 2007

about the electrical activity that accompanies that engage the client in repetitive, novel tasks can
muscle contraction is provided to the patient be effective in reducing upper extremity motor
through visual or auditory feedback. This might be impairment after stroke.
particularly helpful when the degree of muscle Thus, the literature is generally supportive of the
contraction is small and less easily observable ki- application of EMG biofeedback in the rehabilita-
nesthetically or visually, as in the earlier stages of tion of hemiparesis following stroke, with some
stroke recovery or when paresis is more severe. specific advantages in lower extremity functional
Schleenbaker and Mainous12 reported a meta- recovery. This straightforward application of bio-
analysis of eight studies (N = 152) in which there feedback is perhaps one of the most obvious, but
was an effect size of 0.81 (95% confidence interval potentially least informative, applications of bio-
[CI] 0.5 to 1.12) and determined that biofeedback feedback technology, as muscle activity in the
was an effective tool for assisting in the rehabilita- limbs is fairly directly observable without the use
tion of hemiparesis. However, there were method- of electrophysiological amplifiers.
ological problems with this analysis; the authors
included two studies in which the comparison
Swallowing and dysphagia
group was provided with no treatment, potentially
skewing the findings in a positive direction for The act of pharyngeal swallowing is a compli-
biofeedback. cated coordination of several small muscles in the
A later meta-analysis with more appropriate in- mouth, neck, and throat. In cases of dysphagia,
clusion criteria examined the role of EMG biofeed- where control of the muscles of the mouth and
back in improving lower extremity function after throat are affected, the ability to swallow can be
stroke and found that the application of biofeed- lost entirely. Given the difficulty that one might
back was superior to conventional treatment alone have in directly observing the complex of muscles
in rehabilitating ankle dorsiflexion muscle involved in producing a swallow, a system provid-
strength (effect size [ES] = 1.17; 95% CI .50 to ing information about the functioning of specific
1.85; p = .0006) and found a statistical trend for its muscles involved in the process could be ex-
efficacy in improving gait quality (ES = .48; 95% tremely valuable in retraining this ability.
CI –.06 to 1.01; p = .08).13 Logemann and Kahrilas16 reported a single case
In a meta-analysis of EMG biofeedback for the study in which surface EMG (sEMG) biofeedback
rehabilitation of upper extremity mobility and was utilized to retrain specific elements of the
functioning in hemiparetic stroke survivors, pharyngeal swallow of an individual with dysph-
Moreland and Thomson14 found small effect size agia secondary to a medullary infarct at 45 months
increases with the addition of biofeedback com- poststroke. This intervention allowed the indi-
pared to conventional physical therapy. Given the vidual to practice and relearn specific maneuvers
small number of studies included in the analysis that would likely have been too subtle to address
(five), there was a chance of simply failing to detect directly without the assistance of biofeedback.
a statistical difference in this analysis due to lack of This approach was integrated into a swallow
power. The authors concluded that factors such as rehabilitation program, and its effectiveness was
patient preference, cost, and ease of application evaluated on a sample of 25 individuals with dys-
should be determining factors in whether the use phagia poststroke and 20 patients with dysphagia
of biofeedback for the rehabilitation of upper ex- from head and neck cancer resection.17 Ninety-two
tremity mobility is appropriate in individual cases. percent of patients recovering from stroke im-
A more recent synthesis of the literature15 sug- proved their functional intake of food and liquid,
gests that an integrated program of therapy includ- compared to 80% of patients recovering from head
ing biofeedback is likely to yield the best results. and neck cancer. Persons with stroke required
The report indicated that sensorimotor training more therapy sessions, but because of their greater
with the use of imagery and electrical stimulation functional improvement, they had lower cost per
with biofeedback in combination with activities unit of functional change. It should also be noted
Role of Biofeedback 61

that treatment of dysphagia in individuals with pointed out that there may be advantages if limb
stroke improves nutritional status and may impact load measures were included in the analyses,
long-term survival rates.18 which at the time of her review, had not been
specifically examined in hemiparetic patients.
In a more recent Cochrane review, force plat-
Urinary incontinence
form biofeedback was also found to have no im-
According to a recent Cochrane review,19 uri- pact on clinical measures of balance (the Berg
nary incontinence affects 40%–60% of individuals Balance Scale, and Timed Up and Go tests) or sway
admitted to hospitals with stroke. At hospital dis- measures. However, force platform biofeedback
charge, 25% still show some problems and 15% was found to significantly impact stance symmetry
still have incontinence problems at 1 year when using visual feedback (standardized mean
poststroke. This same review indicated that there difference [SMD] –0.68; 95% CI –1.31 to –0.04; p
were insufficient data to evaluate the effectiveness = .04) and concurrent visual and auditory feed-
of biofeedback for urinary incontinence specifi- back (weighted mean difference [WMD] –4.02;
cally in stroke patients. However, Capelini et al.20 95% CI –5.99 to –2.04; p = .00007), reflecting the
reported findings indicating the successful appli- finding predicted by Nichols regarding limb load
cation of biofeedback with pelvic floor strengthen- measures, with stance symmetry serving as a quan-
ing exercises to treat stress urinary incontinence in titative measure of the active use of the paretic
a sample of 14 women. Biofeedback and pelvic limb.22
floor exercises significantly reduced number of In a counterintuitive use of feedback manipula-
urinary leakage episodes and daytime frequency. tion, Bonan et al.23 demonstrated that during
Urodynamic evaluation revealed a significant in- poststroke recovery, reliance of visual feedback
crease in Valsalva leak-point pressure, cistometric may impede recovery of balance. These investiga-
capacity, and bladder volume at first desire to tors compared conventional balance therapy deliv-
void. Thus, biofeedback appears to be a potentially ery and therapy delivery under visual deprivation.
promising intervention for treatment of urinary The results indicated that individuals deprived of
incontinence following stroke, but more research visual information regarding spatial orientation ac-
is needed in this area to demonstrate its efficacy tually improved significantly more on six measures
with this specialized population. of balance than a control group that was allowed to
rely on vision during balance therapy. It is possible
that by depriving the patients of visual cues, the
Balance and gait
intervention improved proprioception by way of
Many stroke survivors have difficulties with bal- necessity.
ance and gait, generally secondary to hemiparesis. Generally, biofeedback appears to be a valuable
Force platform biofeedback is a method of provid- adjunct to conventional therapies for some aspects
ing patients with information about the location of of mobility recovery, balance retraining, and swal-
their center of gravity with reference to the loca- low recovery. Biofeedback also shows promise in
tion of their feet. In cases where proprioception the area of treating incontinence, but more re-
may be impaired, an additional source of informa- search is needed in this domain with stroke survi-
tion about one’s balance may be helpful in regain- vors, specifically.
ing standing stability and improving mobility.
Nichols21 reviewed literature examining the impact
Biofeedback for Cognitive Rehabilitation
of force platform biofeedback on various dimen-
sions of balance. Although this was a qualitative Traditional therapy for cognitive changes fol-
review of the literature, she indicated that there lowing stroke has largely centered on speech
appeared to be no significant advantage to the use therapy for aphasia. However, other interventions
of biofeedback in terms of outcomes related to have been developed to address difficulties in spe-
sway, dynamic stability, or symmetry, but she cific cognitive functions within the last decade.10
62 TOPICS IN STROKE REHABILITATION/JULY-AUG 2007

Until very recently, in the field of stroke rehabilita- Although there are little actual data on the appli-
tion, cognition has been the tool of biofeedback cation of this new approach specifically to stroke
rather than its object. Biofeedback has relied on rehabilitation, two case studies appear in the litera-
cognition to alter the functioning of some other ture. The earliest report by Rozelle and
physiological process, largely EMG activity, as in Budzynski27 describes neurofeedback treatment of
the studies summarized previously. However, a 55-year-old male who was 1 year post a left-sided
there are emerging approaches that utilize the ischemic stroke with posterior temporal/parietal
principles of biofeedback to affect the brain’s activ- infarctions secondary to occlusion of the left inter-
ity directly and, therefore, the cortical substrates of nal carotid artery at the outset of therapy. Prior to
the cognitive functions themselves. This section treatment, the patient reported difficulties with
will focus on two of these emerging therapeutic word finding and halted speech, paraphasia, and
approaches: electroencephalographic (EEG) bio- difficulty focusing his right eye.
feedback, or neurofeedback, and Interactive Met- Quantitative EEG analysis revealed increased
ronome® technology. left-side 4–7 Hz activity and alpha persistence on
eye opening. The patient received a 6-month
course of neurofeedback; training began with a few
EEG biofeedback or neurofeedback
sessions of EEG entrainment feedback, followed
The field of neurofeedback is an exciting new by neurofeedback to inhibit 4–7 Hz activity and
area of application of the principles of biofeedback increase 15–21 Hz activity over sensorimotor and
to stroke rehabilitation. In this approach, elec- speech areas on the left side of the cortex. Follow-
trodes record the EEG activity at one or more given ing treatment, the patient’s quantitative EEG
scalp locations, and a computer displays informa- showed significantly decreased slow wave activity.
tion about the brain’s activity to the patient. Most The authors reported that the patient also demon-
current neurofeedback systems can display a wide strated significantly improved speech fluency, at-
range of information to the practitioner and the tention and concentration, coordination and bal-
patient such as frequency composition, amplitude ance, as well as improved mood.
of activity in a particular frequency band (e.g., Because the most rapid spontaneous recovery
delta 1–4 Hz, theta 4–8 Hz, alpha 8–12 Hz, beta occurs within the first year following a stroke, it is
13–21 Hz, high beta 21–32 Hz, and gamma 32–60 important to note that this patient began
Hz), coherence between two sites in one or more neurofeedback approximately 1 year poststroke.
frequency bands, phase lag, or any of a number of However, since no formal statistics were used in
other derived measures. Then, operant condition- this early case report, the improvements reported
ing combined with various cognitive strategies or cannot be quantified objectively. Nonetheless, this
functional tasks are used to alter the EEG activity early attempt suggests that neurofeedback may be
in the desired direction. Given the relationship applied to stroke recovery with possible benefit to
between EEG activity in particular frequency the patient’s functioning beyond the period of ex-
bands over specific cortical locations and meta- pected recovery.
bolic rates of various cortical structures,24 this ap- A later report by Bearden et al.28 describes the
proach allows the therapist and patient to alter treatment of a 52-year-old male, 1 year post cere-
cortical metabolism and thereby influence neural brovascular event. This man’s stroke resulted in
activity and neuroplasticity in various regions of infarcts in the left thalamus and temporoparietal
the brain.25,26 Because of this direct access to neural areas of the cortex. Following a 14-week course of
functioning, neurofeedback could be used to alter neurofeedback to reduce slow wave activity over
or accelerate the processes of functional reorgani- the affected areas two to three times per week, he
zation of the cortex following stroke, thereby demonstrated significant decreases in 4–7 Hz ac-
speeding functional recovery or in some cases ac- tivity in the left hemisphere and restored alpha
tually enabling functional recovery that would not attenuation upon eye opening. He also demon-
have otherwise occurred. strated statistically significant improvements on
Role of Biofeedback 63

neuropsychological tests of attention, working Interactive metronome technology


memory, divided attention, processing speed, and
sequencing. Another emerging brain-based technology with
Again, these case studies are encouraging, but promise for the field of cognitive rehabilitation
much more research is needed to evaluate the following stroke is Interactive Metronome ®
effectiveness of this approach in comparison to therapy. This technology uses operant condition-
other treatments for postacute rehabilitation of ing of an individual’s motor planning, sequencing,
cognitive impairments related to stroke. timing, and attention through having them engage
In a review of the literature regarding attention in simple, repetitive motor tasks such as clapping
rehabilitation, Michel and Mateer29 report that the hands or tapping the feet in time with a set
there may be specific benefits to attention follow- beat. The system provides both visual and auditory
ing stroke from neurofeedback. Citing studies that feedback to indicate how far off-beat each repeti-
report significant improvements in attention fol- tion of the task is (in milliseconds) and whether
lowing neurofeedback training in children and the repetition was early (before the beat) or late
adults with attention deficit disorder, the authors (after the beat) to allow the individual to alter the
point out that attention difficulties are often asso- rate of movement on a beat-by-beat basis. The
ciated with excessive slow wave activity in the EEG default tempo of the beat is 54 ms but is adjustable
of the frontal cortex in both attention deficit disor- for individuals with limited mobility. Thus, in the
der and after acquired brain injury and stroke. course of just over a second, the individual re-
Laibow et al.30 reported that operant condition- ceives audio and visual feedback about their last
ing to decrease the ratio of theta (4–8 Hz) to beta response, tracks the next beat, adjusts their behav-
(15–30 Hz) activity has been demonstrated to im- ior accordingly, and makes the next response. The
prove overall symptom severity in a number of deceptively simple task is cognitively demanding,
domains in individuals with severe to moderate and many patients find it frustrating and confusing
acquired brain injury (i.e., traumatic brain injury, in the beginning of their treatment. To do well at
stroke, and hemispherectomy). Symptom severity the task, multiple cognitive functions must be syn-
ratings were determined by agreement of chronized and sustained, producing activation and
caregiver, patient, and physician reports. Even coordination of several cortical regions and en-
though this study included patients with brain couraging neuroplasticity throughout the brain.
injury of other etiologies as well as those resulting The current research literature on clinical out-
from stroke, it points out the potential utility of comes following treatment with Interactive Metro-
neurofeedback in this patient population. nome® technology has focused largely on the
In summary, neurofeedback appears to be a prom- remediation of attention deficit disorder in chil-
ising new treatment for cognitive and emotional dren.31 However, these initial efforts have revealed
problems following stroke that can provide measur- a wide range of benefits that may translate well
able benefits to patients beyond the time range of into stroke rehabilitation. Specifically, statistically
expected spontaneous improvement. Further re- significant improvements were demonstrated in
search is needed to determine the relative clinical attention, motor planning and coordination, lan-
efficacy of this approach in comparison to and in guage processing, reading, and the regulation of
combination with other treatment approaches to cog- aggression. Currently, there are several ongoing
nitive rehabilitation following stroke. An important studies investigating the applicability of Interactive
question for future research, from this author’s point Metronome® technology to rehabilitation of trau-
of view, is whether neurofeedback can impact spe- matic brain injury, Parkinson’s disease, and devel-
cific cognitive functions (e.g., attention, memory, opmental disorders.
verbal fluency) that result from the focal lesions pro- Because it addresses the underlying cognitive
duced by stroke, or whether the effects of this functions of processing speed, attention, timing,
intervention appear to be more general (e.g., glo- coordination, planning, and sequencing, Interac-
bal cognitive functioning). tive Metronome® therapy has great potential to be
64 TOPICS IN STROKE REHABILITATION/JULY-AUG 2007

helpful in many cognitive domains that may be provided by biofeedback in this application is
affected by stroke, but more research is clearly largely available to us directly through other av-
needed on this promising new approach. enues (visual, kinesthetic, etc.). However, in cases
where the information is not easily accessible
Summary and Discussion through other means, as in the intricate maneuvers
of swallowing, or the regulation of cortical poten-
Biofeedback appears to be an effective adjunct to tials and metabolic rates, or the fine-grained aware-
conventional therapies for a number of the prob- ness of timing and cognitive coordination, biofeed-
lems that patients encounter following stroke. It back becomes most valuable. I predict that areas of
appears to assist with some aspects of the rehabili- research building on this observation will have the
tation of hemiparesis and mobility recovery and is greatest benefits to our patients and our under-
valuable in the rehabilitation of swallowing in pa- standing of the healing and recovery process.
tients with dysphagia. Biofeedback also shows
promise in the domain of controlling urinary in-
Recommendations for the Application of
continence.
Biofeedback in Stroke Rehabilitation
In regard to cognitive rehabilitation, the emerg-
ing field of EEG biofeedback, or neurofeedback, Recommendations regarding the application of
appears to hold great promise for the rehabilitation biofeedback interventions in conjunction with
of attention, language processing, working conventional approaches to rehabilitation must be
memory, and even motor coordination. The pre- made from both an evidence-based position and
liminary reports of case studies and a single re- from the vantage of clinical utility. An account of
ported application of this treatment approach have the evidence to support the use of biofeedback in
been encouraging. However, more detailed re- stroke rehabilitation has been the focus of this
search should be carried out to explore the mecha- article. However, a quality that is more difficult to
nisms of action and direct application of quantify is that of clinical utility. Biofeedback has
neurofeedback to specific focal difficulties that unique clinical utility in that it can powerfully
stroke survivors often encounter. demonstrate to patients that they can exert control
Similarly, Interactive Metronome® technology over aspects of their functioning of which they do
appears to be very promising for the rehabilitation not otherwise have awareness. The impact of this
of the processes underlying multiple higher level demonstration alone could be an argument that
cognitive functions and has shown some positive the technology should be applied early in the
initial results in other populations with cognitive course of rehabilitation. Shifting the locus of con-
difficulties, but more research will be required to trol to an internal orientation is empowering; an
assess its effectiveness with stroke survivors in individual recovering from stroke is certainly
particular. likely to benefit from increased feelings of control
In the areas that are otherwise difficult to access, over the functioning of the body.
biofeedback supplies information that is most Also, there will likely be some added benefit to
valuable and has the largest physiological and the natural course of expected spontaneous recov-
functional impact. Given that the process of heal- ery to include these interventions as early as pos-
ing is a conscious one, and that consciousness sible. More active forms of biofeedback (e.g., force
naturally assists the regulation and direction of the platform biofeedback for balance) should be ap-
healing process, we can only directly change those plied as soon as the patient is medically stable
things of which we can be consciously aware. If a enough to begin active rehabilitation. However,
process is hidden from our view, we are less able to less strenuous interventions such as heart rate vari-
correct any problems with its functioning. This is ability biofeedback, which has been shown to re-
the value of biofeedback in general. It reveals hid- duce stress and depression in samples with coro-
den processes and enables conscious regulation of nary heart disease,32 may be applied even earlier
them. In the case of motor recovery, this role may with good result.
be somewhat less valuable, because the information In sum, biofeedback is a useful tool in the recov-
Role of Biofeedback 65

ery of function following stroke and should be self-efficacy, to emphasize an internal locus of con-
provided as a part of the conventional program of trol, and to contribute substantially to the recovery
rehabilitation. It has great potential to improve of function in a number of domains.

REFERENCES

1. Centers for Disease Control and Prevention. Dispari- 15. Barreca S, Wolf SL, Fasoli S, Bohannon R. Treatment
ties in deaths from stroke among persons aged <75 interventions for the paretic upper limb of stroke
years—United States, 2002. MMWR Morb Mortal Wkly survivors: a critical review. Neurorehabil Neural Re-
Rep. 2002;54:477–481. pair. 2003;17(4):220–226.
2. Centers for Disease Control and Prevention. Preva- 16. Logemann JA, Kahrilas PJ. Relearning to swallow
lence of disabilities and associated health conditions— after stroke—application of maneuvers and indirect
United States, 1991-92. MMWR Morb Mortal Wkly Rep. biofeedback: a case study. Neurology. 1990;40(7):
1994;43:730–739. 1136–1138.
3. American Heart Association. 2000 Heart and Stroke 17. Crary MA, Carnaby Mann GD, Groher ME, Helseth
Statistical Update. Dallas, TX: American Heart Associa- E. Functional benefits of dysphagia therapy using
tion; 1999. adjunctive sEMG biofeedback. Dysphagia.
4. Page SJ, Gater DR, Bach-y-Rita P. Reconsidering the 2004;19(3):160–164.
motor recovery plateau in stroke rehabilitation. Arch 18. Elmstahl S, Bulow M, Ekberg O, Petersson M,
Phys Med Rehabil. 2004;85(8):1377–1381. Tegner H. Treatment of dysphagia improves nutri-
5. Paolucci S, Antonucci G, Grasso MG, et al. Functional tional conditions in stroke patients. Dysphagia.
outcome of ischemic and hemorrhagic stroke patients 1999;14(2):61–66.
after inpatient rehabilitation: a matched comparison. 19. Thomas LH, Barrett J, Cross S, French B, Leathley M,
Stroke. 2003;34(12):2861–2865. Sutton C, Watkins C. Prevention and treatment of
6. Erkinjuntti T, Roman G, Gauthier S, Feldman H, urinary incontinence after stroke in adults. Cochrane
Rockwood K. Emerging therapies for vascular demen- Database Syst Rev. 2005(3):CD004462.
tia and vascular cognitive impairment. Stroke. 20. Capelini MV, Riccetto CL, Dambros M, Tamanini JT,
2004;35(4):1010–1017. Herrmann V, Muller V. Pelvic floor exercises with
7. Duncan PW, Horner RD, Reker DM, et al. Adherence to biofeedback for stress urinary incontinence. Int Braz
postacute rehabilitation guidelines is associated with J Urol. 2006;32:462–469.
functional recovery in stroke [editorial comment]. 21. Nichols DS. Balance retraining after stroke using
Stroke. 2002;33(1):177–178. force platform biofeedback. Phys Ther. 1997;77(5):
8. Van Peppen RPS KG, Wood-Dauphinee S, Hendriks 553–558.
HJM, Van der Wees PhJ, Dekker J. The impact of 22. Barclay-Goddard R, Stevenson T, Poluha W, Moffatt
physical therapy on functional outcomes after stroke: MEK, Taback SP. Force platform feedback for stand-
What’s the evidence? Clin Rehabil. 2004; 18:833–862. ing balance training after stroke. Cochrane Database
9. Walker MF, Leonardi-Bee J, Bath P, et al. Individual Syst Rev. 2004;(4):CD004129. Available at: http://
patient data meta-analysis of randomized controlled www.mrw.interscience.wiley.com/cochrane/
trials of community occupational therapy for stroke clsysrev/articles/CD004129/frame.html.
patients. Stroke. 2004;35(9):2226–2232. 23. Bonan IV, Yelnik AP, Colle FM, et al. Reliance on
10. Cicerone KD, Dahlberg C, Malec JF, et al. Evidence- visual information after stroke. Part II: effectiveness
based cognitive rehabilitation: updated review of the of a balance rehabilitation program with visual cue
literature from 1998 through 2002. Arch Phys Med deprivation after stroke: a randomized controlled
Rehabil. 2005;86(8):1681–1692. trial. Arch Phys Med Rehabil. 2004;85(2):274–278.
11. Brosseau L, Wells GA, Finestone HM, et al. Ottawa 24. Alper KR, John ER, Brodie J, Gunther W, Daruwala R,
panel evidence-based guidelines for post-stroke reha- Prichep LS. Correlation of PET and qEEG in normal
bilitation. Top Stroke Rehabil. 2006;13(2):1–269. subjects. Psychiatry Res: Neuroimaging. 2006;
12. Schleenbaker RE, Mainous AG III. Electromyographic 146(3):271–282.
biofeedback for neuromuscular reeducation in the 25. Lee JS, Lee DS, Oh SH, et al. PET evidence of
hemiplegic stroke patient: a meta-analysis. Arch Phys neuroplasticity in adult auditory cortex of postlingual
Med Rehabil. 1993;74(12):1301–1304. deafness. J Nucl Med. 2003;44(9):1435–1439.
13. Moreland JD, Thomson MA, Fuoco AR. Electromyo- 26. Detre JA. Clinical applicability of functional MRI. J
graphic biofeedback to improve lower extremity func- Magn Reson Imaging. 2006;23(6):808–815.
tion after stroke: a meta-analysis. Arch Phys Med 27. Rozelle GR, Budzynski TH. Neurotherapy for stroke
Rehabil. 1998;79(2):134–140. rehabilitation: a single case study. Biofeedback Self
14. Moreland J, Thomson MA. Efficacy of electromyo- Regul. 1995;20(3):211–228.
graphic biofeedback compared with conventional 28. Bearden TS, Cassisi JE, Pineda M. Neurofeedback
physical therapy for upper-extremity function in pa- training for a patient with thalamic and cortical
tients following stroke: a research overview and meta- infarctions. Appl Psychophysiol Biofeedback.
analysis. Phys Ther. 1994;74(6):534–543. 2003;28(3):241–253.
66 TOPICS IN STROKE REHABILITATION/JULY-AUG 2007

29. Michel JA, Mateer CA. Attention rehabilitation fol- Tuchman RF, Stemmer PJ Jr. Effect of interactive
lowing stroke and traumatic brain injury: a review. metronome training on children with ADHD. Am J
Eur Med Phys. 2006;42:59–67. Occup Ther. 2001;55(2):155–162.
30. Laibow RE, Stubblebine AN, Sandground H, Bounias 32. Nolan RP, Kamath MV, Floras JS, et al. Heart rate
M. EEG-neurobiofeedback treatment of patients variability biofeedback as a behavioral neurocardiac
with brain injury: Part 2: Changes in EEG parameters intervention to enhance vagal heart rate control. Am
versus rehabilitation. J Neurother. 2001;5:45–71. Heart J. 2005;149(6):1137.
31. Shaffer RJ, Jacokes LE, Cassily JF, Greenspan SI,

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