189-

Visual feedback after stroke with the balance

performance monitor: two single-case studies
CM Sackley and BI Baguley Division of Stroke Medicine, City Hospital, Nottingham

Research over the past decade had indicated the effectiveness of visual
feedback as a method of training stance symmetry and weight-transference
after stroke. This study was carried out to assess the efficacy of the Balance
Performance Monitor (BPM) in providing feedback. A reversal ABAB single-case
experimental design was used with two patients at different stages poststroke.
Assessments of motor function and independence in functional tasks (ADL)
were made, as well as the measures of stance symmetry. The results indicated
large improvements in symmetry, with both patients achieving levels within the
normal range after five treatments. Functional skills also improved. Although the
limitations of single-case studies are recognized, such dramatic improvements
suggest that the BPM is an effective method of providing feedback and that this
approach to treatment enhances the effects of physiotherapy and could be used
more frequently after stroke.

Introduction stand with an abnormally large amount of their

bodyweight through their unaffected leg, with
The most frequentlynoted sequela of motor estimated frequencies ranging from 61%3 to over
impairment after stroke is hemiplegia, which 80%.~ Three studies have calculated the mean

produces asymmetry of both gait and posture.
Patients tend to exhibit abnormal patterns of
stance and gait; these are described extensively in
physiotherapy texts.l>2 Such texts also claim that
patients favour their unaffected leg for weight-
bearing in standing and walking.
In recent years research evidence has substan-
tiated the clinical observations that patients do
Address for correspondence: CM Sackley, Division of Stroke
Medicine, City Hospital, Hucknall Road, Nottingham, UK.
percentage of bodyweight the unaffected legon
and estimates range from 70% to 74% of total
bodyweight,3,7,8 far outside the normal ranges of
between 43 % and 57% .99
The clinical importance of poor stance symme-
try is dependent on its relation with impaired
motor function and resulting dependence in
functional abilities. Increased weight-bearing on
the unaffected leg is directly linked with a
decrease in motor and functional performance.3
This relationship has been demonstrated at two

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190
months after stroke and still persists at six
months.
Conventional therapeutic intervention, using
neurofacilitatory techniques or concepts (such
as the Bobath approach), intended to
are
encourage normal movement, part of which
involves correcting weight-bearing abnormalities.
Unfortunately these techniques have not been
formally evaluated and the theoretical ration-
ale supporting their use is now a matter of
controversy.10 However, methods of augmented
feedback, based on motor-learning theoiy from
a behavioural background have demonstrated
positive results. 7,11-13
Since 1970 external methods of feedback have
been used to enhance skill acquisition after
stroke. The advantage of using equipment to
enhance the verbal and tactile feedback from the
therapist is that it is quantifiable and precise
It can also provide more sensitive measures than
the visual and tactile subjective evaluation of the
therapist. 15
The effects of augmented feedback on postural
control have been studied, and research using
postural feedback devices has demonstrated
improvements in standing posture. The first
of these studies was that by Wannstedt
and Herman,16 who used augmented sensory
feedback via an auditory signal provided from
a limb-load monitor. Of the 30 ambulatory
stroke patients included, 27 (77%) corrected
their symmetry of weight-bearing by enhancing
their limb-loading on the paretic limb.
More recently, Shumway-Cook et at.7 used
force-plate information to provide centre of
pressure feedback to 16 hemiplegic patients
and to provide an accurate assessment of stance
symmetry. This was compared with conventional
therapy in eight control patients. The experimen-
tal group was found to have significant increases
in symmetry of limb-loading.
The above studies assumed that postural
symmetry was linked to functional ability and
that patients would automatically be able to
transfer their newly learned skills to functional,
task-orientated movement. Two studies have
examined the transfer of skills learned from
postural training to gait, with conflicting results.
Winstein et al, 12 provided visual feedback from
force-place information to an experimental group
of 17 hemiplegic patients. These subjects were
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trained an average of 30-45 minutes per day,
five days a week, for three to four weeks.
Both the experimental group and a control
group of 21 matched subjects received conven-
tional physiotherapy during the trial period. At
the end of the study the experimental group
achieved a more symmetrical standing posture
than the control group, but this difference did
not generalize to measures of gait performance.
However, the adequacy of the control group may
be questioned, especially as the experimental
group received more therapy treatment time in
total.
A report of two single-case ’ABAB’ designs&dquo;
described the effects of visual feedback on weight
distribution and gait. Patients received EMG
biofeedback to the arm in week A (to act as
a control) and visual feedback training in week
B. An immediate and substantial improvement in
the symmetry of weight distribution was demon-
strated, and this was sustained over time. Some
carry over to the gait pattern was seen, but there
was no measurable improvement in gross motor
function. This study does not give the frequency
or duration of treatment, so the total treatment
time is unclear, and it may therefore be difficult
to evaluate behavioural changes.
A recent randomized controlled trial examined
the effects of visual feedback and the transfer of
training to motor and ADL function. 17 Twenty-six
stroke patients were randomly allocated either
to visual feedback or to a placebo computer
program. Patients received 12 sessions of 20
minutes as part of a functionally orientated
physiotherapy session (lasting approximately
one hour), three times a week. Independ-
ent assessments of motor and ADL function
were completed before, after the four weeks’
treatment and again eight weeks after that.
Significant improvements in stance symmetry,
gross motor function and ADL performance were
observed for the treatment group at the four-week
assessment.
The Balance Performance Monitor (BPM) was
developed to provide the therapist with an
efficiency and effective method of using feedback
techniques (both visual and audio) in a clinical
environment. Unlike the equipment used in previ-
ous research studies it was important that the
BPM possessed the qualities that would enable
it to be used successfully within the constraints

of clinical rather than pure research practice.
Although the results of past studies support the
use of augmented feedback to enhance the effects
of rehabilitation, especially physiotherapy, it was
necessary to test the ability of the BPM to provide
this facility. For this reason a detailed systematic
investigation of the effects on individual patients
(a single-case experimental design) was chosen
as it provides a large amount of detail of the
effects of treatment. Such effects may be lost
when examining a group of patients such as
stroke patients, where the lack of homogeny and
diversity of symptoms make a large comparative
sample difficult to achieve and the clinical validity
of group comparisons questionable. This method
of investigation is becoming more popular in the
field of rehabilitation research. 18
Methods
A reversal ABAB experimental design was used.
The patients were recruited while undertaking
their existing rehabilitation routine, all inter-
vention was additional to this. Patients were
randomly allocated to receive feedback training
in either the A or B section and received routine
physiotherapy treatment in the other section.
Subjects were included if they were presenting
with their first stroke with unilateral symptoms
and were within the age range of 30-80 years.
Both subjects were able to understand instruc-
tions and give informed consent. They exhibited
abnormal stance symmetry (greater than 7% from
the midline) and were excluded if they had
obvious lower limb deformities (e.g. amputation,
joint replacement) or severe visual deficits.
Subject 1
KW is a male aged 42 with a history of hyper-
tension and chronic renal failure. It was his first
stroke and resulted in a left hemiplegia with no
speech or perceptual deficits. He was admitted
to a general medical ward and transferred to a
specialist rehabilitation unit after 12 weeks and
began the research study at 14 weeks poststroke.
At this stage poststroke it is considered that the
majority of recovery has already taken place.l9
Subject 2
DG is a female aged 56 with a history of transi-
ent ischaemic attacks over the last eight years.
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191
Her stroke resulted in a left hemiplegia with no
speech deficits but some perceptual problems.
She was admitted to a general medical ward and
transferred to a specialist rehabilitation unit after
five weeks; she commenced the study at seven
weeks poststroke.
Assessments
The Rivermead Motor Assessment
Motor function was assessed with the
Rivermead Motor Assessment.2° This scale
was developed to provide a standardized,
ranked assessment of physical recovery after
stroke. The inter-rater and test-retest reliability
have been found to be acceptable. It was designed
as a tool both for routine clinical use and research
purposes. The Rivermead Motor Assessment
consists of three parts, each consisting of between
10 and 15 items arranged in order of difficulty. As
this test is a Guttman-scaled assessment2l there is
no need to complete the section once a patient has
failed three consecutive items. The patient scores
the number of the last successfully completed item
prior to the three failures.
Ten Point Activity of Daily Living (ADL) scale
Functional ability was measured with the Ten
Point Activity of Daily Living (ADL) scale.22 This
is a Guttman-scaled assessment and is reliable if
administered formally (by observing behaviour)
or informally (self-reporting, either as an inter-
view or questionnaire). It includes items such
as feeding, dressing and toileting. Patients are
scored as ’independent’ or ’dependent’ on each
item. The test is stopped after three consecutive
failures and the score (which summarizes the
patient’s level of ability) is equal to the number
of the most difficult item successfully completed.
Apparatus
The Balance Performance Monitor
The Balance Performance Monitor (BPM)
(SMS Healthcare, Elizabeth House, Elizabeth
Way, Harlow, Essex CM19 5TL, UK) is a light-
weight portable unit designed to provide a variety
of visual and auditory feedback. It provides objec-
tive measurements of left-right weight distribu-
tion, postural sway and anterior-posterior weight
distribution on each foot. The equipment consists
of the feedback unit and two movable footplates
192
(Figure 1). The software is IBM compatible and
can be used to provide a permanent record of the
patient’s progress. Patients were assessed while
standing with one foot on each of the footplates,
which were kept a uniform distance apart, without
any postural correction. The test lasts for 30
seconds during which the patient is asked to
stand still with their arms by their side and to
fix their gaze on a suitable marker in the midline
(Figure 1). The BPM display was positioned away
from the patient so the subject did not receive
any feedback during the test. The BPM calculates
the left-right weight distribution, described as the
’balance coefficient’, as a number from 0 to 100,
with 0 being the midline and deviation from this to
the left or right as 0-100.
Figure 1 The Balance Performance Monitor (BPM):
feedback unit
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Procedure ........
Independent assessments
Two baseline assessments, one on recruitment
and one after one week, consisted of the measure
of stance symmetry, the balance coefficient,
completion of the Rivermead Motor Assessment
(RMF) and the Ten Point Activity of Daily
Living (ADL) scale. These assessments (as with
all others) were completed by a therapist who
was not treating the patient and was blind to the
patient’s treatment schedule.
Patients began with treatment A or B and were
assessed at the end of each week (3, 4, 5 and
6). Subjects were then assessed at a follow-up in
weeks 7 and 8 (Figure 2).
The visual feedback training was given
during week A and additional conventional
physiotherapy based on the Bobathl approach
in week B. Both treatments lasted approximately
one hour, depending on the patient’s tolerance.
Feedback from the BPM was incorporated into
a physiotherapy treatment which consisted of
a ’warm-up’ period followed by approximately
twenty minutes visual feedback, finished by
practising the new skills in a functional task,
such as gait-training. During the feedback session
patients were asked to perform a variety of tasks
aimed at improving stance symmetry. These
increased in difficulty, ranging from sitting
to standing, stride and step-standing (for a
detailed account of treatment with the BPM
see Sackley et al.23). Treatment was orientated
towards dynamic, functional skills.
Results
Subject 1 started feedback therapy in week 4 and
subject 2 in week 3. Table 1 gives the balance
coefficient data and demonstrates the improve-
ment in balance coefficient scores that occurred
during the feedback treatment (A). Figures 3 and
4 demonstrate the changes graphically. Tables 2
and 3 give the functional scores.
Discussion .
After one week’s visual-feedback treatment (five
sessions) both patients had reduced their stand-
ing asymmetry and regained a normal pattern of
 193

Table 2 Activity of daily living scores .

NT no visual feedback treatment

=

T = visual feedback

Table 3 Motor function scores

Figure 2 Flow chart of study procedure. BC balance

=

coefficient. RMF =
Rivermead Motor Function Assessment.
ADL Activity of daily living assessment. All intervention
=

was in addition to the patients’ rehabilitation programme

(which included physiotherapy).

Table 1 Balance coefficients

NT no visual feedback treatment
=

T = visual feedback

weight distribution. This agrees with the studies

discussed in the introduction7,11,12,16,17 in finding
that augmented feedback may improve stance
symmetry after stroke. It also demonstrates that
the BPM is an effective tool for providing visual
feedback.
Some of the improvement was lost in week
NT no visual feedback treatment
= B (additional physiotherapy without visual
T visual feedback
=
feedback), but the follow-up assessments

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194

demonstrated that the effects of treatment

were retained. The improvements were gained
very quickly with very little treatment when
compared with the intense and prolonged courses
of therapy that patients receive after stroke. The
treatment schedules of 10 treatments given in
groups of five were chosen arbitrarily; it may
be more effective in the clinical environment to
start with an initial burst of treatment and then
provide regular ’top-ups’.
Transfer of training effects was seen and both
motor function and ADL scores increased after
the first week of visual feedback. Although the
numerical changes appear to be minor, the clinical
significance of these is great. The scales chosen,
especially the Ten Point ADL, are very short
and rather insensitive, so any changes recorded
are clinically relevant. The most difficult item of
the Ten Point ADL is bathing, and so a ceiling
effect can be seen when patients progress to more
difficult tasks, which may have been the case in
this study.

Figure 4 Graph of balance coefficients at each weekly

assessment for
subject 2

Single-case research designs have become

increasingly popular as a method of evaluating
physiotherapy information,18 although some
disagreement exists as to the number of data
points which should be collected. Kazdin24 recom-
mends the multiple collection of data throughout
the week, whereas Offenbacher25 considers that
patient fatigue and the limitation of the clinical
environment require that fewer assessments be
made (as in this case).
Although it is not possible to generalize the
results of two patients to the stroke population
as a whole, an interesting observation is that
visual feedback training was effective with two
patients at different stages after stroke. One
could be considered chronic (longer than three
months poststroke) and the other acute (within
three months). A larger study may indicate the
time at which it is most effective.
From the results of this and other studies
Figure 3 Graph of balance coefficients at each weekly it seems reasonable to recommend that visual
assessment for
subject 1 feedback is used more widely as an adjunct

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to physiotherapy after stroke, especially so as
there is little research evidence to support
other treatment methods. The results of this
study suggest that it may be a more efficient
method of retraining, enhancing the effects of
physiotherapy, as both patients had received daily
therapy since their stroke and yet had not learned
to weight-bear on their affected leg within the
normal range.
To conclude, visual feedback with the BPM
enhanced the effects of physiotherapy and
improved stance symmetry; there was also a
transfer of training effects to functional skills.
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