The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Biofeedback
Electromyographic biofeedback (EMG-BFB) training versus control, level I (randomized controlled trial [RCT]): Grade C+ for motor function at end of treatment, 5 weeks (clinically important benefit demonstrated without statistical significance); grade D for physical abilities at end of treatment, 5 weeks (no benefit demonstrated); grade D+ for physical abilities at follow-up, 9 months, and motor function at follow-up, 9 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with postacute stroke.
EMG-BFB training for the wrist versus control, level II (controlled clinical trial [CCT]): Grade B for grip strength at follow-up, 3 months, and motor function at end of treatment, 3 months, and at follow-up, 3 and 9 months (clinically important benefit demonstrated); grade C+ for grip strength at end of treatment, 3 months (clinically important benefit demonstrated without statistical significance); grade D+ for grip strength at follow-up, 9 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with chronic stroke.
EMG-BFB relaxation training for the shoulder versus control, level I (RCT): Grade C+ for pain relief at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for active shoulder range of motion (ROM) at end of treatment, 2 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke.
EMG-BFB training for the upper extremity versus control, level II (CCT): Grade A for motor function (time to make a circle with tip of olecranon) at end of treatment, 6 months (clinically important benefit demonstrated); grade C+ for motor function (time to abduct shoulder to 90º) at end of treatment, 6 months. Patients with chronic stroke.
EMG-BFB training for the lower extremity versus control, level I (RCT) and level II (CCT): Grade A for change in timed ambulation on carpeted surface at end of treatment, 4 weeks (clinically important benefit demonstrated); grade B for ankle ROM (change in active ankle dorsiflexion) and knee ROM (change in active knee flexion) at end of treatment, 3 months, ankle strength at follow-up, 6 weeks, (clinically important benefit demonstrated); grade C+ for knee ROM (decrease of hyperextension) at end of treatment, 4 weeks, and follow-up, 4 weeks, gait speed at end of treatment, 4 weeks and 2 months, and follow-up, 4 weeks, gait quality at end of treatment, 2 months, gait cycle time at end of treatment, 6 weeks, mobility at end of treatment, 3 months, change in timed ambulation on smooth surface and improvement in ankle angle at heel strike at end of treatment, 4 weeks, and ankle strength at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for ankle ROM (active ankle ROM) at end of treatment, 6 weeks, and follow-up, 2 months, ankle angle at end of treatment, 6 weeks and 2 months, step length at end of treatment, 4 and 6 weeks, and follow-up, 3 months, stride width at follow-up, 3 months, decrease of spasticity at end of treatment, 2 months, quality of life at end of treatment, 2 months, functional status at end of treatment, 2 months (no benefit demonstrated); grade D+ for improvement in lower extremity support asymmetry at end of treatment, 4 weeks, ankle angle (improvement in ankle angle at toe-off at end of treatment, 4 weeks (clinically important benefit favoring control demonstrated without statistical significance); grade D for knee angle at end of treatment, 6 weeks, ankle ROM (change in active ROM) at end of treatment, 4 weeks, stride width at end of treatment, 6 weeks, ankle angle (ankle angle at heel strike) at end of treatment, 2 months, step length at end of treatment, 2 months, improvement in lower extremity support asymmetry at follow-up, 4 weeks, global neurological status at end of treatment, 2 months (no benefit demonstrated but favoring control). Patients with acute chronic stroke.
EMG-BFB training for the lower extremity versus placebo, level II (CCT): Grade B for ankle strength at end of treatment, 6 weeks, and follow-up, 6 weeks, gait quality and ankle ROM at follow-up, 6 weeks (clinically important benefit demonstrated); grade C+ for gait quality and ankle ROM at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for step length and stride width at end of treatment, 4 weeks, and follow-up, 3 months, and active ankle ROM at end of treatment, 6 weeks, and follow-up, 3 months (no benefit demonstrated). Patients with subacute-chronic stroke.
EMG-BFB training for the shoulder versus placebo, level I (RCT): Grade C+ for upper extremity motor function at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for upper extremity motor function at follow-up, 6 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke.
EMG-BFB training for the elbow versus placebo, level I (RCT): Grade C+ for passive elbow ROM at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade D for active elbow ROM at end of treatment, 3 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
EMG-BFB training for hand versus placebo, level I (RCT): Grade C+ for functional status at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor recovery at end of treatment, 4 weeks (no benefit demonstrated); grade D+ for wrist ROM at end of treatment, 4 weeks. Patients with post-acute stroke.
Rhythmic positional BFB training versus control, level I (RCT): Grade A for ankle ROM at end of treatment, 12 weeks, and gait speed at end of treatment, 12 weeks, and follow-up, 3 months (no benefit demonstrated). Patients with chronic stroke.
Audio and visual feedback training with general relaxation versus control, level II (CCT): Grade C+ for active knee ROM at end of treatment, 3 months (clinically important benefit demonstrated without statistical significance); grade D+ for active ankle ROM and mobility at end of treatment, 3 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with chronic stroke.
Video feedback training versus control, level II (CCT): Grade B for decrease of unilateral neglect (baking tray task) at end of treatment, 2 days (clinically important benefit demonstrated); grade C for decrease of unilateral neglect (line bisection task) at end of treatment, 2 days (no benefit demonstrated); grade D for decrease of unilateral neglect (line cancellation task) at end of treatment, 2 days (no benefit demonstrated but favoring control). Patients with subacute stroke.
BFB training versus functional electrical stimulation (FES), level I (RCT): Grade C+ for stride length at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for ankle and knee angle and gait cycle time at end of treatment, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
Force-feedback training for upper extremity versus control, level I (RCT): Grade C for motor function at end of treatment, 6 weeks, and follow-up, 8 weeks, and dexterity at follow-up, 8 weeks (no benefit demonstrated); grade D for coordination at end of treatment, 6 weeks, and follow-up, 8 weeks, and for dexterity at end of treatment, 6 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Force-feedback training for lower extremity versus control, level I (RCT): Grade C+ for gait speed at end of treatment, 6 weeks, and gait endurance (2-minute walking test) at follow-up, 8 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function and mobility (Timed Up & Go) at end of treatment, 6 weeks, and follow-up, 8 weeks, gait speed at follow-up, 8 weeks, and gait endurance at end of treatment, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100