[ research report ]

CRISTINE AGRESTA, PT, PhD1 • ALLISON BROWN, PT, PhD2

Gait Retraining for Injured and Healthy

Runners Using Augmented Feedback:
A Systematic Literature Review

R
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egular cardiovascular exercise, such as running, has Multiple prospective studies

many known physical and psychological benefits, have documented the presence
of altered running mechanics
including weight control, decreased hypertension,
in runners who develop run-
decreased blood glucose in type 2 diabetes, and improved ning injuries. 6,24,25,35,37 These
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

mood state.29,44 However, running does not come without findings suggest a causal relation-
risk. Lower extremity injury rates have been reported to range from ship between abnormal running me-
19% to 79% in runners.34 Risk factors are multifaceted and include chanics and subsequent injury. While
there is some evidence to support the
both external factors, such as high or ficient muscle strength, insufficient impairment-based treatment model
a sudden increase in weekly mileage,33 muscle length,15,33 or abnormal running in treating running-related injuries,
and internal factors, such as insuf- mechanics.26,40 a growing body of literature suggests
that addressing these altered running
mechanics may be of good long-term
TTSTUDY DESIGN: Systematic literature review. methodological quality. There was a consensus in
Journal of Orthopaedic & Sports Physical Therapy®

benefit. 17,20,26 One method of modify-

TTOBJECTIVES: This review sought to determine
the efficacy of real-time visual and/or auditory
feedback for modifying kinematics and kinetics
during running gait.
TTBACKGROUND: Real-time visual and auditory
feedback has gained popularity in the clinical and
research settings. Rehabilitation time and injury
prevention may be improved when clinicians are
able to modify running mechanics in a patient
population.
TTMETHODS: A thorough search of PubMed,
CINAHL, and Web of Science from 1989 to January
2015 was performed. The search sought articles
that examined real-time visual or auditory feed-
back for the purposes of modifying kinematics or
kinetics in injured or healthy runners. Study design
and methodological quality were rated using a
20-point scale.
TTRESULTS: Ten studies were identified for inclu-
sion in the review, 2 of high and 8 of moderate
the literature that the use of real-time feedback is
effective in reducing variables related to ground
reaction forces, as well as in positively modify-
ing previously identified risky lower extremity
kinematic movement patterns in healthy runners
and those with patellofemoral pain and chronic ex-
ertional compartment syndrome. No one method
of feedback was identified as being superior. Mirror
and 2-dimensional video feedback were identified
as potential methods for running-gait modification
in a clinical setting.
TTCONCLUSION: In conjunction with traditional
therapeutic interventions, real-time auditory and
visual feedback should be considered for treating
injured runners or addressing potentially injurious
running mechanics in a healthy population.
J Orthop Sports Phys Ther 2015;45(8):576-584.
doi:10.2519/jospt.2015.5823
TTKEY WORDS: auditory, biomechanics, injury,
mirror, patellofemoral pain, visual
ing a runner’s mechanics is through
visual or auditory feedback. A few
studies have investigated the effect of
providing such feedback to runners
with currently symptomatic patello-
femoral pain (PFP). 4,27,41 While these
studies have documented improved
running mechanics following feedback
sessions, more importantly, they have
also shown decreased running-related
pain and symptoms. These findings
suggest that feedback training may be
an effective approach to treat running
injuries. The aim of this review was to
evaluate the efficacy of real-time visual
and/or auditory feedback to modify ki-
nematic and kinetic gait patterns that
have been associated with running
injury.

1
Human Performance Innovation Lab, School of Kinesiology, University of Michigan, Ann Arbor, MI. 2School of Health Related Professions, Rutgers, The State University of New
Jersey, Newark, NJ. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter
or materials discussed in the article. Both authors contributed equally to this work. Address correspondence to Dr Cristine Agresta, Central Campus Recreation Building, 401
Washtenaw Avenue, Ann Arbor, MI 48109. E-mail: cristine.agresta@gmail.com t Copyright ©2015 Journal of Orthopaedic & Sports Physical Therapy®

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TABLE 1 Results of Electronic Database Search
Key Word Search
(gait OR locomotion OR running) AND (feedback OR retraining)
AND runners
(feedback OR gait retraining) AND (load OR force OR impact)
AND (gait OR running OR locomotion)
(feedback OR gait retraining) AND (step OR stride OR
spatiotemporal) AND (gait OR running OR locomotion)
(running OR gait) AND (retraining OR feedback) AND
(visual OR step rate)
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(feedback OR gait retraining) AND (kinematic OR kinetic) AND
(gait OR running OR locomotion)
Total yield
*Values are n. Total yield across databases, n = 974.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
METHODS
Search Strategy
P
ubMed, CINAHL, and Web of Sci-
ence were searched from 1989 to
January 2015 for peer-reviewed
publications that investigated the ef-
fect of feedback training during run-
Journal of Orthopaedic & Sports Physical Therapy®
ning. Searches were limited to articles
in English with human subjects 18 years
and older. Key words and search terms
included the following: feedback, gait
retraining, kinematic, kinetic, spatio-
temporal, stride, step, gait, running, lo-
comotion, load, force, and impact. The
sequence with search retrievals is sum-
marized in TABLE 1. For the purpose of this
review, “feedback” refers to augmented or
extrinsic feedback. Augmented feedback
is defined as information from an external
source, provided to the runner regarding
his or her individual performance relative
to the desired performance.31 The run-
ner intentionally uses this information
(feedback) to make corrections to his or
her running gait to achieve a targeted
performance parameter. Two reviewers
(C.A. and A.B.) independently screened
articles based on titles and abstracts.
Studies were accepted or excluded based
on inclusion and exclusion criteria. Fol-
lowing this first screening, each reviewer
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45-08 Agresta.indd 577
PubMed CINAHL Web of
Yield Yield Science Yield
33 4 56
171 58
178 42
147 51
204 30
733 185 56
independently retrieved appropriate
articles and a full-text screen was per-
formed. Following the full-text screen,
there was discussion by the reviewers
until an agreement was reached on the
final list of included articles. The FIGURE
shows a flow diagram summarizing the
selection process. In January 2015, a sec-
ond search was conducted to confirm that
no additional articles had been published
that met the inclusion/exclusion criteria.
Inclusion and Exclusion Criteria
To be considered for inclusion, studies
had to include interventions that uti-
lized feedback training during running;
to report on kinematic, kinetic, muscle
electromyography, or spatiotemporal
variables; and to focus on the lower ex-
tremity. Studies were excluded if they
reported on interventions that included
running-gait retraining without feed-
back on task performance; participants
with prosthetic limbs, neurological im-
pairments, or congenital impairments;
feedback during tasks other than run-
ning; and children or participants under
18 years of age.
Assessment of Methodological Quality
The methodological quality of each study
was independently rated by the 2 review-
ers using a 20-point scale proposed by
Burns and Miller.3 This appraisal tool
consists of 16 items focused on study
design, experimental control, study par-
ticipants, methodology, and outcomes.
The first item, addressing study design,
is worth 5 points. Each additional item
is worth 1 point, for a maximum score of
20. Once scored, studies were assigned
a quality rating of high (score range, 14-
20), medium (score range, 7-13), or low
(score range, 1-6), based on their final
scores. Articles with disagreement in
quality scores between raters were reread
and discussed to reach consensus.
Data Extraction and Analysis
Each author independently reviewed the
articles and extracted the following data:
study population, number of participants
in each group, participant demograph-
ics, intervention protocol, method of
feedback delivery, follow-up, outcomes,
and statistical significance. Due to het-
erogeneity of study design and outcome
measures, a meta-analysis could not be
performed. Data analysis focused on the
gait parameters targeted for modification
by the feedback training. These param-
eters included hip and pelvis kinematics,
joint moments, spatiotemporal param-
eters, and ground reaction forces.
RESULTS
Study Selection
T
he initial literature search
yielded a total of 974 potential arti-
cles. Nine hundred fifty-five articles
were removed after screening titles and
abstracts and removing duplicates. Three
articles were added from hand searches,
which left a total of 22 articles that were
read independently by the 2 reviewers
for content and quality. After reading the
full-text articles, 9 studies were excluded
for lack of focus on feedback training
as an intervention or its influence on
running characteristics.1,2,5,16,18,19,30,42,43
Another paper was excluded because it
provided data on the same population
as the original article.39 Finally, 2 pa-
7/15/2015 3:31:41 PM
 [ research report
pers were excluded for poorly defined
participant characteristics and proto-
col.10,21 Thus, a total of 10 articles were
considered appropriate and included for
review.4,7-9,11-13,22,27,41 A summary of study
characteristics and outcomes is provided
in TABLE 2. Of the 10 studies included in
this review, only 2 were classified as being
of high quality, whereas the remaining 8
were of medium quality. The individual
item scores and total quality assessment
score for each study are summarized in
TABLE 3. All studies lost quality points for
a lack of assessor or participant blinding.
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With only 2 randomized controlled trials
in the group, many studies lost quality
points for study design as well as for lack
of an experimental control group.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Feedback Retraining Protocol
Feedback schedule, running duration,
and the duration of training varied
across studies. Four of the 10 studies
used the same feedback schedule for
training,4,8,27,41 with feedback given con-
sistently for 4 sessions, then gradually
withdrawn over 4 sessions. In these 4
studies, participants were not permit-
Journal of Orthopaedic & Sports Physical Therapy®
ted to run outside of gait-retraining ses-
sions. Clansey et al7 provided 20 minutes
of continuous feedback during all six
35-minute running sessions. Two stud-
ies11,12 used videotape feedback, a digital
metronome to increase step rate, and
verbal feedback to reduce the tendency to
heel strike upon ground contact. Verbal
feedback was offered during the 25- to
30-minute running sessions following a
series of drills aimed at improving run-
ning mechanics (see Diebal et al12 for
details on running drills). Messier and
Cirillo22 provided concurrent visual and
verbal feedback during minutes 1 and
10 of a 20-minute training session. The
remaining 2 studies investigated the im-
mediate effects of feedback using a single
training session.9,13 Crowell et al9 used a
single 30-minute running session divid-
ed into warm-up, feedback, no-feedback,
and cool-down periods. Eriksson et al13
tested participants across 11 trials, while
providing nonsimultaneous auditory or
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45-08 Agresta.indd 578
Records identified through
database search, n = 974
• PubMed, n = 733
• Web of Science, n = 56
• CINAHL, n = 185
Full-text articles assessed for
eligibility, n = 22
Studies included in the review,
n = 104,7-9,11-13,22,27,41
FIGURE. Study selection flow diagram.
visual feedback. Selected gait parame-
ters, in isolation or in combination, were
targeted during each trial.
All but 17 of the 10 studies included
instructions from the experimenters
for a “strategy or way to run” to achieve
the desired outcome, and all but 14 of
the 10 studies incorporated both visual
and auditory feedback information dur-
ing the training sessions. Nine of the 10
studies utilized visual feedback, 5 in the
form of a visual representation of the
metric to change,7-9,13,27 1 using a full-
length mirror,41 and 3 using video of the
participant.11,12,22
Outcome Variables
Noehren et al27 demonstrated a sig-
nificant overall reduction in peak hip
adduction angle (HADD) and peak con-
tralateral pelvic drop following feedback
training in runners with PFP. Although it
was not statistically significant, peak hip
internal rotation was also reduced. Mod-
ifications for HADD and contralateral
pelvic drop persisted at the 1-month fol-
low-up. Also, in runners with PFP, Willy
et al41 found significant reductions in
stance-phase peak HADD, peak contra-
]
Records identified through hand
search, n = 3
Records excluded after screening
titles, abstracts, and duplicates,
n = 955
Full-text articles excluded, n = 12
• Feedback training was not
primary intervention,
n = 91,2,5,16,18,19,30,42,43
• Sample population duplicated in
another study, n = 139
• Poorly defined subject character-
istics and protocols, n = 210,21
lateral pelvic drop, and peak hip internal
rotation after mirror feedback training.
Only changes in HADD remained sig-
nificant at the 1-month follow-up.
Following 6 weeks of training to in-
crease step rate and change to a forefoot
strike pattern, runners with chronic ex-
ertional compartment syndrome (CECS)
significantly increased step frequency,
decreased step length, and reduced
ground reaction forces (GRFs).11,12 After
8 feedback training sessions, Cheung and
Davis4 demonstrated reductions in GRF
that were maintained at the 3-month
follow-up. During a single feedback ses-
sion, the 5 participants in the Crowell et
al9 study were able to make considerable
reductions in the magnitude of the GRFs.
In a similar study by Crowell and Davis,8
GRFs were reduced after feedback train-
ing, and these changes persisted at the
1-month follow-up. Similarly, Clansey
et al7 also reported a reduction in the
magnitude of the GRFs after training;
however, all measures returned to base-
line values at the 1-month follow-up. In
addition, Clansey et al7 found significant
differences in ankle and foot-strike angle
after runners received visual and auditory
7/15/2015 3:31:42 PM
 TABLE 2 Study Characteristics and Outcomes

Participant Control Gait Parameter Outcome

Study Characteristics Group Protocol to Change Measures Outcomes*
Cheung and 3 females with No Dosage: 8 sessions over 2 wk, 15- Foot strike VIP, VALR, VILR VIP preintervention: 1.3  0.1 BW, 1.7  0.2 BW, 1.7 
Davis4 PFP; age to 30-min sessions, SSS 0.1 BW; postintervention: 1.4  0.1 BW, 1.5  0.1
range, 26-32 y; Instruction/strategy: verbal BW, 1.1  0.1 BW
10-30 km/wk (“shorten stride length, avoid VALR preintervention: 48.2  6.9 BW/s, 55.8  7.6
RFS landing”) BW/s, 41.4  8.5 BW/s; postintervention: 37.7  7.7
Feedback: auditory sensor in heel BW/s, 38.7  8.3 BW/s, 35.2  8.6 BW/s
of Pedar insole VILR preintervention: 69.6  7.0 BW/s, 72.3  7.9
BW/s, 41.4  8.5 BW/s; postintervention: 37.7  7.7
BW/s, 38.7  8.3 BW/s, 35.2  8.6 BW/s
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Clansey et al7 3 healthy male 10 matched Dosage: 6 sessions over 3 wk, 20 GRF VIP, VALR, VILR PTA preintervention, 10.67  1.85 g; postintervention,
RFS; mean controls min, 3.7 m/s 7.39  1.48 g†
age, 33 y; 30 Feedback: visual (traffic symbol), VALR preintervention, 66.54  17.45 BW/s; postinter-
km/wk auditory (pitch) vention, 54.62  14.41 BW/s†
VILR preintervention, 113.87  33.01 BW/s; postinter-
vention, 92.10  27.06 BW/s†
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

VIP preintervention, 2.72  0.17 BW; postintervention,

2.62  0.16 BW
Crowell et al9 5 healthy females; No Dosage: 1 session, 30 min, SSS GRF VIP, VALR, VILR PTA preintervention, +6% g; postintervention, –60% g†
mean age, 26 Instruction/strategy: verbal (“run VIP preintervention, –6% BW; postintervention, –30%
y; 32 km/wk softer”) at beginning of first BW†
retraining session VALR preintervention, –19% BW/s; postintervention,
Feedback: visual (graph of PTA) –39% BW/s†
VILR preintervention, –15% BW/s; postintervention,
–39% BW/s
Crowell and 10 healthy RFS No Dosage: 8 sessions over 2 wk, 15- GRF VIP, VALR, VILR PTA preintervention to postintervention difference,
Journal of Orthopaedic & Sports Physical Therapy®

Davis8 (6 male, 4 to 30-min sessions, SSS –48% g†

female); 16 Instruction/strategy: verbal (“run VIP preintervention to postintervention difference,
km/wk softer”) at beginning of first –19% BW
retraining session VALR preintervention to postintervention difference,
Feedback: visual (graph of PTA) –32% BW/s†
VILR preintervention to postintervention difference,
–34% BW/s†
Diebal et al11 2 RFS; CECS; age, No Dosage: three 30-min sessions Foot strike, Step length, Step frequency: preintervention, 2.74 and 2.66 steps/s;
21 y per week for 6 wk step rate step rate, postintervention, 2.99 and 3.37 steps/s
Feedback: visual (videotape of peak VGRF, Step length: preintervention, 1.15 and 1.21 m; postinter-
runner), verbal (“run quietly”; impulse vention, 1.05 and 1.02 m
explanation of proper running Peak VGRF: preintervention, 2.68 and 2.42 BW;
technique) postintervention, 2.44 and 2.21 BW
Impulse: preintervention, 193.64 and 382.10 ns;
postintervention, 183.56 and 314.19 ns
Table continues on page 580.

feedback focusing on peak tibial accelera-
tion, with the runners demonstrating a
more plantar-flexed ankle position dur-
ing early stance.
After 5 weeks of feedback training tar-
geting running mechanics, Messier and
Cirillo22 found that runners responded
favorably to the desired modifications
set by the investigators. These modifica-
tions included a significantly more dorsi-
flexed ankle position during early stance
(P<.01), as well as greater knee flexion
during the support phase (P<.001).
However, contrary to the intention of the
feedback training, runners also exhibited
increased vertical center of mass dis-
placement (P<.01) compared to control
participants.
In the study by Eriksson et al,13 well-
trained distance runners were able to
immediately manipulate their running
mechanics by at least 10% of their base-
line measures. However, these runners
were not able to use a specific combina-
tion of step frequency and vertical dis-
placement to achieve a predetermined
power output. A reduction in step fre-

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 [ research report ]

TABLE 2 Study Characteristics and Outcomes (continued)

Participant Control Gait Parameter Outcome

Study Characteristics Group Protocol to Change Measures Outcomes*
Diebal et al12
10 RFS; CECS; No Dosage: three 25-min sessions Foot strike, step Step length, Step frequency: preintervention, 2.71  0.11 steps/s;
mean  SD per week for 6 wk rate step rate, postintervention, 2.86  0.17 steps/s†
age, 20.2  Feedback: visual (videotape of support Step length: preintervention, 1.18  0.08 m; postinter-
1.5 y runner), verbal (“run quietly”; time, peak vention, 1.12  0.10 m†
explanation of proper running VGRF, Support time: preintervention, 0.30  0.03 s; postin­
technique) impulse, tervention, 0.28  0.02 s
weight- Peak VGRF: preintervention, 2.40  0.18 BW; postin­
acceptance tervention, 2.34  0.22 BW†
rate Impulse: preintervention, 0.38  0.02 BW/s; postinter-
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vention, 0.36  0.02 BW/s†

Weight-acceptance rate: preintervention, 29.66  5.54
BW/s; postintervention, 26.43  5.71 BW/s†
Eriksson et al13 18 (11 male, No Dosage: 11 trials, 4.4 m/s VCOM displace- ... VCOM displacement: change across trials, 80.0  7.3
7 female); Feedback: visual (graph of VCOM ment, knee cm to 105.2  5.4 cm
healthy; mean displacement, step frequency, angle, ankle Step frequency: change across trials, 95.4  2.7
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

 SD age, 28 power), verbal (“run higher/ angle steps/min to 107.7  5.2 steps/min
 6.4 y lower,” “too much/too little
power,” “shorter/longer steps”)
Messier and 11 healthy, physi- 11 matched Dosage: 15 sessions over 5 wk; VCOM displace- ... VCOM displacement: preintervention, 8.81  0.44 cm;
Cirillo22 cally active controls 20 min; submaximal speed ment, step postintervention, 11.07  0.43 cm†
females determined by HR and RPE frequency Knee angle: preintervention, 136.0°  1.8°; postinter-
Instruction/strategy: verbal vention, 134.3°  1.3°†
(explanation of proper running Ankle angle: preintervention, 94.5°  2.2°; postinter-
technique and reminder of vention, 95.5°  0.8°†
variables to modify)
Feedback: visual (videotape of
Journal of Orthopaedic & Sports Physical Therapy®

runner)
Table continues on page 581.

quency caused a large increase in verti-
cal displacement when visual feedback
was given. This effect was not observed
with auditory feedback. In this study,
when given the choice, most runners
opted to adjust vertical center of mass
displacement rather than step frequency
to achieve desired power.
DISCUSSION
effective in reducing the magnitude of
GRFs, including vertical instantaneous
loading rate, vertical average loading rate,
and vertical impact peak. High vertical
loading rates and impact peaks have been
measured in cohorts of runners with over-
use running injuries, such as tibial stress
fractures, plantar fasciitis, and medial tib-
ial stress syndrome.23,28 If clinicians can
utilize feedback to decrease loading rates
and impact forces experienced by the low-
loading rate, and vertical instantaneous
loading rate after providing feedback to
eliminate the heel strike pattern demon-
strated by runners with PFP. Participants
were able to modify their gait pattern and
reduce vertical impact peak and loading
rates. Although this was a case series with
only 3 runners, the study findings were
all maintained after a 3-month follow-up.
Both studies focusing on runners with
CECS11,12 used a combination of running

T
his systematic review synthesiz-
es the current evidence on the effica-
cy and utility of augmented feedback
during running. The results demonstrate
the need for more rigor and higher-quality
research design in future studies.
Feedback for Kinetic Variables
There was a consensus in the literature
that the use of augmented feedback is
er extremity, this intervention may help
to prevent the occurrence or recurrence
of such injuries. This systematic review
included 7 articles4,7-9,11,12,27 that examined
GRFs during running, only 3 of which
examined an injured population.4,11,12 All
3 studies4,11,12 provided feedback in an at-
tempt to alter foot-strike pattern. In their
case series, Cheung and Davis4 examined
vertical impact peak, vertical average
drills, step-rate manipulation, and verbal
feedback to encourage a forefoot strike
pattern. Participants were successful in
modifying their running technique and
significantly reduced peak vertical GRF
and impulse.
Feedback for Kinematic Variables
Four studies13,22,27,41 of high or medium
quality assessed the effects of real-time

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 TABLE 2
Participant Control
Study Characteristics Group
Noehren et al 27
10 females with No
PFP; age
range, 18-45 y;
10 km/wk
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Willy et al41 10 females with No
PFP; age
range, 18-40 y;
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
10 km/wk
Abbreviations: BW, body weight; CECS, chronic exertional compartment syndrome; CPD, contralateral pelvic drop; GRF, ground reaction force; HADD, hip
Journal of Orthopaedic & Sports Physical Therapy®
adduction angle; HIR, hip internal rotation; HR, heart rate; PFP, patellofemoral pain; PTA, peak tibial acceleration; RFS, rearfoot strikers; RPE, rate of
perceived exertion; SSS, self-selected speed; VALR, vertical average loading rate; VCOM, vertical center of mass; VGRF, vertical ground reaction force; VILR,
vertical instantaneous loading rate; VIP, vertical impact peak.
*Values are mean  SD unless indicated otherwise.
†
Significant difference (P<.05).
feedback on kinematic variables. Among
these studies, there was agreement that
auditory and/or visual feedback, re-
gardless of the method of delivery, was
effective in modifying lower extrem-
ity movement patterns that have been
associated with running-related inju-
ries.24,25,32,38 Two studies examining the ef-
fects of real-time feedback on kinematic
changes at the pelvis and/or hip27,41 in
runners with PFP utilized a faded-feed-
back design, providing runners with visu-
al feedback regarding their stance-phase
HADD angle. In addition, Willy et al41
provided runners with verbal feedback
to modify their lower extremity position.
Both studies noted improved hip and pel-
vis mechanics after feedback.
45-08 Agresta.indd 581
Study Characteristics and Outcomes (continued)
Gait Parameter
Protocol to Change
Dosage: 8 sessions over 2 wk; Hip and pelvis
15-30 min; SSS kinematics
Instruction/strategy: verbal (“con-
tract gluteal muscles,” “run
with knees pointing straight
ahead”)
Feedback: visual (graph of HADD)
Dosage: 8 sessions over 2 wk; Hip and pelvis
15- to 30-min; SSS kinematics
Instruction/strategy: verbal (“run
with your knees apart,” “run
with your kneecaps pointing
straight ahead,” “squeeze your
buttocks”)
Feedback: visual (full-length
mirror), verbal (“run with your
knees apart,” “run with your
kneecaps pointing straight
ahead,” “squeeze your but-
tocks”)
A few prospective studies have identi-
fied greater stance-phase HADD and hip
internal rotation in runners with PFP25 or
iliotibial band syndrome.14,24 The results
of these prospective studies suggested
that abnormal running mechanics might
play a role in the development of PFP and
iliotibial band syndrome. Therefore, real-
time feedback in runners with PFP is a
potentially promising intervention for
clinical implementation. Future studies
should consider addressing the efficacy
of real-time feedback in runners with il-
iotibial band syndrome as well.
One medium-quality study13 and 1
high-quality study22 examined the effects
of feedback on kinematic modifications
not specific to the hip or pelvis. In their
journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015 | 581
Outcome
Measures Outcomes*
HADD, HIR, VIP: preintervention, 1.43  0.2 BW; postintervention,
CPD, VIP, 1.28  0.1 BW
VALR, VILR VILR: preintervention, 65.0  15 BW/s; postinterven-
tion, 44.0  7.0 BW/s
VALR: preintervention, 55  13 BW/s; postintervention,
44.0  7.0 BW/s
CPD: preintervention, –9.4°  2.5°; postintervention,
–7.1°  1.6°†
HADD: preintervention, 22.0°  1.5°; postintervention,
16.5°  2.2°†
HIR: preintervention, 11.0°  4.1°; postintervention,
8.3°  6.0°
HADD, HIR, CPD: preintervention, –9.0°  2.5°; postintervention,
CPD –7.1°  2.2°†
HADD: preintervention, 20.7°  1.0°; postintervention,
14.8°  3.1°†
HIR: preintervention, 8.6°  5.4°; postintervention,
7.1°  8.7°
studies, Messier and Cirillo22 and Eriks-
son et al13 found that the verbal and visual
feedback provided to runners had a sig-
nificant effect on their desired kinematic
and kinetic modifications.
Clinical Implementation
The purpose of this systematic review
was not to establish whether a superior
method of feedback may exist, but to de-
termine the efficacy of feedback training
in a running population. As such, in this
review, no mode of feedback delivery
was clearly identified as outperforming
another. However, in a clinical popula-
tion, feasibility may be as meaningful as
efficacy. Few clinics have access to nec-
essary technology adequate to capture
7/15/2015 3:31:44 PM
 [ research report ]
TABLE 3 Methodological Quality Ratings for Each Article

Messier Crowell Crowell Willy Cheung Eriksson Noehren Clansey Diebal Diebal
Methodological Quality Item and Cirillo22 and Davis8 et al9 et aI41 and Davis4 et al13 et al27 et al7 et al11 et al12
Study design criteria* 5 4 3 4 1 4 4 5 1 4
Additional criteria (1 point each)
Clear experimental controls used 1 0 0 0 0 0 0 1 0 0
Prospective study completed 1 1 1 1 1 1 1 1 1 1
Blinding of assessors and subjects used 0 0 0 0 0 0 0 0 0 0
Clear description of subjects/group 1 1 1 1 1 1 1 1 1 1
Balanced baselines between groups or stable 1 0 0 0 1 0 0 1 1 0
Downloaded from www.jospt.org at on August 10, 2015. For personal use only. No other uses without permission.

across single subject

Target behaviors observable and measurable 1 1 1 1 1 1 1 1 1 1
Clear description of intervention methods 1 1 1 1 1 0 1 1 1 1
Attrition rate explained or minimal (<20%) 1 1 1 1 1 1 1 1 1 1
Clear description of observable or measurable 1 1 1 1 1 1 1 1 1 1
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

outcomes
Statistical analysis described or conducted 1 1 1 1 1 1 1 1 1 1
appropriately
Appropriate reliability methods described or used 0 0 0 0 0 0 0 1 0 0
Appropriate validity methods described or used 0 0 0 0 0 0 0 0 0 0
Clear conclusions drawn from results 1 1 1 1 1 1 1 0 1 1
Clear description of follow-up and maintenance 0 1 0 1 1 0 1 1 1 1
outcomes
Journal of Orthopaedic & Sports Physical Therapy®

Total score 15 13 11 13 11 11 13 16 11 13
*1 point, case series/case report; 2 points, crossover study; 3 points, single-subject study design; 4 points, cohort study; 5 points, randomized controlled trial.
From “Tutorial: the effectiveness of neuromuscular electrical stimulation (NMES) in the treatment of pharyngeal dysphagia: a systematic review” by Michael I.
Burns and Robert M. Miller in Journal of Medical Speech-Language Pathology, 19(7), 13-24. Copyright ©2011 Plural Publishing, Inc. All rights reserved. Used
with permission.

3-D kinematic or kinetic data in their
patients. In addition, due to the velocity
of limb movement during running, real-
time verbal feedback that is responsive
to modifications in running mechanics
can be quite a challenge for clinicians.
Nevertheless, this review identified 2
methods of visual feedback provision
that are both feasible and effective for
clinical use. Three studies11,12,22 utilized
a standard video camera with the im-
age projected on a monitor or laptop to
provide runners with visual feedback.
This visual feedback, in conjunction
with scripted verbal cues, was effective
in modifying selected kinematic vari-
ables. This study design is perhaps the
most feasible in a clinical setting. Wil-
ly and colleagues41 examined another
mode of visual feedback that could eas-
ily be implemented in a clinical setting.
The authors found that a mirror placed
in front of the runner to provide visual
feedback during a treadmill run was ef-
fective at modifying selected hip and
pelvis kinematics in runners with PFP.
While effective and feasible, this study
examined only frontal plane hip and
pelvis kinematics. Further investigations
into the application of this approach to
address foot/ankle or knee kinematic
modifications should be considered. In
addition, sagittal plane visual feedback
is not feasible with this design and re-
mains a limitation in the applicability of
this feedback technique.
One additional and persistent limita-
tion to the application of feedback in a
clinical setting is identifying those patients
who would benefit from visual or verbal
feedback and the feedback parameters
for such patients. Seven of the included
studies in this review4,7,8,11,12,27,41 utilized
3-D motion analysis, an instrumented
treadmill, or in-shoe foot sensors to screen
for participation or to assess variables il-
lustrating running technique. This type of
screening is uncommon in a clinical set-
ting. Furthermore, although clinicians can
visually screen patients for the presence of
abnormal kinematics using 2-dimension-
al video analysis, screening patients for
abnormal kinetics is considerably more
challenging. A recent study by Wille and

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45-08 Agresta.indd 582 7/15/2015 3:31:44 PM

 colleagues36 suggests that certain 2-di-
mensional kinematic variables can pro-
vide insight into loading patterns during
running. These variables can be collected
using a single video camera, which is of-
ten available in a clinic setting. Further
exploration into this area is necessary for
accurate clinical application of real-time
visual or auditory feedback.
Feedback Frequency
There was an enormous amount of di-
versity in the literature with respect
to the frequency of feedback and the
Downloaded from www.jospt.org at on August 10, 2015. For personal use only. No other uses without permission.
number of feedback sessions. With all
this variability, there was no clear in-
dication that one specific format of
feedback was superior to another, as all
study designs appeared to be effective
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in positively modifying kinematic and
kinetic variables. However, superior re-
sults were demonstrated when runners
were provided with multiple feedback
sessions.4,7,8,22,27,41
Limitations of Current Research
and Future Directions
One clear limitation of the included
Journal of Orthopaedic & Sports Physical Therapy®
studies is the lack of diagnostic diversity
among study participants. Five studies
examined the effects of real-time feed-
back in injured runners.4,11,12,27,41 The
remaining 5 studies7-9,13,22 examined the
effects of feedback in healthy runners.
While the use of biofeedback in popula-
tions of healthy runners demonstrates
the clinical feasibility of this interven-
tion, potentially for prevention purposes,
there is no evidence that achieving the
biomechanical modifications strived for
during feedback training will positively
affect pain and functional outcomes in
an injured population outside of those
with PFP or CECS. Future studies are
needed to look at a broader range of di-
agnoses and their response to real-time
auditory or visual feedback.
A second limitation of the included
studies concerns the implementation of
concurrent auditory and visual feedback.
Only 1 study13 separated auditory from
visual feedback. Study results suggested
journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015 | 583
45-08 Agresta.indd 583
that runners responded more favorably to
auditory feedback; however, the order of
auditory and visual feedback delivery was
not randomized, limiting the strength of
any conclusion. There is a need for future
studies to separate visual feedback, audi-
tory feedback, and “coaching,” to estab-
lish which approach or combination of
approaches is most effective.
CONCLUSION
C
onsistently, medium- to high-
quality studies supported the effi-
cacy of real-time visual or auditory
feedback in modifying what was consid-
ered less-than-optimal lower extremity
mechanics in a running population. No
conclusions can be made as to the best
type of feedback or feedback design, nor
can any recommendations be made as to
what patient population would best re-
spond to real-time feedback. t
KEY POINTS
FINDINGS: Real-time visual and auditory
feedback is effective in modifying run-
ning mechanics in healthy runners and
runners with PFP and CECS.
IMPLICATIONS: Clinicians should consider
the use of real-time visual and auditory
feedback in treating runners with PFP
who present with frontal plane hip and
pelvis kinematic deviations.
CAUTION: No recommendations can be
made with regard to implementation of
real-time feedback in injured runners
aside from those with PFP and CECS.
Additionally, no recommendations can
be made regarding preferential choice of
feedback mode or delivery.
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@ MORE INFORMATION
Med Sci Sports Exerc. 2013;45:1120-1124. http:// nopathy in novice runners: a prospective study.
dx.doi.org/10.1249/MSS.0b013e31828249d2 Gait Posture. 2009;29:387-391. http://dx.doi.
26. Noehren B, Pohl MB, Sanchez Z, Cunning- org/10.1016/j.gaitpost.2008.10.058 WWW.JOSPT.ORG

VIEW Videos on JOSPT’s Website

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the associated videos for an article, click on Supplementary Material and
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584 | august 2015 | volume 45 | number 8 | journal of orthopaedic & sports physical therapy

45-08 Agresta.indd 584 7/15/2015 3:31:46 PM

 jospt perspectives for patients

Running
Improving Form to Reduce Injuries
J Orthop Sports Phys Ther 2015;45(8):585. doi:10.2519/jospt.2015.0503

R
unning is often perceived as a good option for
“getting into shape,” with little thought given to the
form, or mechanics, of running. Most people assume
that running is something natural that we simply
know how to do. However, as many as 79% of all run-
ners will sustain a running-related injury during any given year.
If you are a runner—casual or serious—you should be aware
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that poor running mechanics may contribute to these injuries.
A study published in the August 2015 issue of JOSPT reviewed
the existing research to determine whether running mechanics
could be improved, specifically with the help of real-time visual
or audio feedback. The ability to improve running form could
be important in treating running-related injuries and helping
injured runners return to pain-free running.

NEW INSIGHTS
A B
Researchers reviewed 974 published studies and
identified 10 high- and medium-quality studies
that examined the effectiveness of visual and
audio feedback for improving running mechanics.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Overall, the evidence supported the use of real-time

feedback. Using feedback tools, physical therapists
were able to help runners (1) decrease the force
with which their feet hit the ground during running,
and (2) improve running form at the hips, knees,
and ankles. For visual feedback, runners watched
themselves run in a mirror or viewed a video of their
running while a physical therapist coached them on
how to improve their form. Audio feedback consisted
of verbal coaching from the physical therapist, or the
use of simple tools such as a metronome, to improve
Journal of Orthopaedic & Sports Physical Therapy®

running cadence.

PRACTICAL ADVICE
BENEFITS OF VISUAL AND AUDIO FEEDBACK. Evidence supports the use of real-time visual and audio feedback to Research shows that runners can improve their
improve running form. (A) The runner on the treadmill exhibits poor running form. (B) Visual feedback on the screen running mechanics using visual and/or audio feedback
and audio cues from the physical therapist are used to provide the runner with the necessary feedback to improve her training while being coached by a physical therapist.
running mechanics. As a result of improved running form, runners may
reduce their risk of injury. In addition, evaluation and
For this and more topics, visit JOSPT Perspectives for Patients online at www.jospt.org. correction of running form may benefit those who
This JOSPT Perspectives for Patients is based on an article by Agresta and Brown titled “Gait Retraining for Injured have knee or leg pain when running. If you already
and Healthy Runners Using Augmented Feedback: A Systematic Literature Review” (J Orthop Sports Phys Ther have a running-related injury or want to reduce
2015;45(8):576-584. doi:10.2519/jospt.2015.5823). your risk of sustaining one in the future, this kind of
supervised feedback can help. For more information
This Perspectives article was written by a team of JOSPT’s editorial board and staff. Deydre S. Teyhen, PT, PhD, Editor, on improving your running form, as well as other
and Jeanne Robertson, Illustrator. strategies to reduce your risk of injury during running,
contact your physical therapist specializing in
orthopaedic and sports-related injuries.

JOSPT PERSPECTIVES FOR PATIENTS is a public service of the Journal of Orthopaedic & Sports Physical Therapy. The information and recommendations
contained here are a summary of the referenced research article and are not a substitute for seeking proper health care to diagnose and treat this condition.
For more information on the management of this condition, contact your physical therapist or health care provider specializing in musculoskeletal disorders.
JOSPT Perspectives for Patients may be photocopied noncommercially by physical therapists and other health care providers to share with patients. The
official journal of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA) and a recognized
journal of more than 30 international partners, JOSPT strives to offer high-quality research, immediately applicable clinical material, and useful supplemental
information on musculoskeletal and sports-related health, injury, and rehabilitation. Copyright ©2015 Journal of Orthopaedic & Sports Physical Therapy ®

journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015 | 585

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