Effects of gait training with auditory biofeedback on biomechanics and talar cartilage characteristics in individuals with chronic ankle instability: A randomized controlled trial

Gait-Training Interventions for Individuals With Chronic Ankle Instability: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic ankle instability (CAI) is a condition known to negatively affect lower extremity gait biomechanics during walking. Gait-training interventions have been proposed as a potential strategy to improve faulty movement patterns associated with CAI.

OBJECTIVE

To determine if gait-training interventions influence lower extremity biomechanics during walking in individuals with CAI.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Literature searches were conducted in PubMed, CINAHL, SPORTDiscus, and MEDLINE from database inception through September 15, 2022.

STUDY SELECTION

Eligible studies were published in English and included randomized controlled trials, studies with a repeated-measures design, and descriptive laboratory studies in which authors measured the biomechanical outcomes (kinematics, kinetics, and electromyography) of a gait-training intervention during walking in individuals with CAI.

DATA EXTRACTION

One author extracted study design, participant characteristics, sample size, intervention type (device and biofeedback), intervention length, and biomechanical outcome measures (kinematics, kinetics, and electromyography).

DATA SYNTHESIS

Gait-training interventions were broadly categorized into device (destabilization and novel gait-training devices) and biofeedback (visual, auditory, and haptic delivery modes). When appropriate, meta-analyses were conducted using a random-effects model to compare mean differences and SDs before and after the gait-training intervention.

RESULTS

Thirteen studies were included. Meta-analyses were conducted only for single-session gait-training studies. Authors of 11 studies reported kinetic outcomes. Meta-analyses showed the location of center of pressure was shifted medially from 0% to 90% of stance (effect size [ES] range, -0.35 to -0.82), contact time was decreased in the medial forefoot (ES = -0.43), peak pressure was decreased for the lateral midfoot (ES = -1.18) and increased for the hallux (ES = 0.59), and the pressure time integral was decreased for the lateral heel (ES = -0.33) and the lateral midfoot (ES = -1.22) and increased for the hallux (ES = 0.63). Authors of 3 studies reported kinematic outcomes. Authors of 7 studies reported electromyography outcomes. Meta-analyses revealed increased activity for 200 milliseconds after initial contact for the fibularis longus muscle (ES = 0.83).

CONCLUSIONS

Gait-training protocols improved some lower extremity biomechanical outcomes in individuals with CAI. Plantar-pressure outcome measures seemed to be most affected by gait-training programs, with improvements including decreasing the lateral pressure associated with increased risk for lateral ankle sprains. Gait training increased electromyographic activity after initial contact for the fibularis longus muscle. Authors of few studies have assessed the effect of multisession gait training on biomechanical outcome measures. Targeted gait training should be considered when treating patients with CAI.

Dancers With Chronic Ankle Instability Have Different Regional Plantar Force During Single-Leg Jump Landing

Background: It is already known that the prevalence of ankle sprain is high in dancers, leading to chronic ankle instability (CAI) and, consequently, affecting jump landing. Therefore, methods that allow the early identification of jump landing alterations related to CAI are necessary. Research Question: This study aimed to investigate if regional plantar force estimated from plantar pressure distribution is different between dancers with and without ankle instability during jump landing. Methods: Female dancers with (n = 12) and without (n = 14) CAI performed single-leg jumps on a force plate (FP), with the insole of a dynamic plantar pressure system inside the ballet shoe. Peak vertical ground reaction force (measured by FP) and peak plantar force of 8 different foot regions (estimated by plantar pressure distribution) were compared between the groups in the first 200 ms after landing, using the t-test and 2-way ANOVA, respectively. Results: No differences were found between the groups considering the peak vertical ground reaction force. There was a higher plantar force on the lateral hindfoot in the group with CAI. Significance: Considering that the higher plantar force on the lateral hindfoot is in accordance with the greater inversion found in people with ankle instability and during sprains, insole dynamic plantar pressure systems were able to identify differences in the jump landing of dancers with and without ankle instability and could be used to early identify risky landing patterns, as well as in real-time feedback during treatment or preventive exercise programs.

A review of concurrent sonified biofeedback in balance and gait training

BACKGROUND

Sonified biofeedback is a subtype of auditory biofeedback that conveys biological data through specific non-verbal sounds. It can be designed to provide augmented biomechanical feedback in near-real-time when provided as "concurrent" biofeedback. As a practice that developed spanning across engineering and the arts, sonified biofeedback can extend beyond simple tones and beeps, towards more fully incorporating music in movement training. Sonified biofeedback may leverage the motivational aspects of music in movement training, the neuroplasticity benefits demonstrated from participation in music-based interventions, and neurological auditory-motor coupling, all while providing task-relevant cues to facilitate motor (re)learning. Sonified biofeedback may also provide similar benefits as rhythmic cueing (e.g., rhythmic auditory stimulation), or added benefits because sonified biofeedback does not impose a strict isochronous rhythm when it follows rhythms that are driven by outputs of the motor control system. In this review paper, the unique opportunity presented by concurrent sonified biofeedback as a movement training tool for balance and gait is introduced and discussed.

RESULTS AND DISCUSSION

This review paper brings together prior research from clinical, engineering, and artistic design sources using sonified biofeedback in balance and gait training across diverse end-users to highlight trends, reveal gaps in knowledge, and provide perspective for future work in the area. The goal was to review progress and critically assess research using sonified biofeedback during movement training for postural control or gait. 49 papers were selected based on their experimental investigation and statistical analyses of the effects of using sonified biofeedback to assist in movement training for feet-in-place balance tasks (20 papers) or gait tasks such as walking and running (29 papers). The sound design choices, experimental design features, and movement training results are summarized and reviewed. All but two studies reported at least one statistically significant positive effect of training with sonified biofeedback in biomechanical, clinical, or psychosocial measures. Conversely, only seven studies shared any negative effect on one biomechanical, clinical, or psychosocial measure (with five of these studies also reporting at least one other positive effect). After describing these encouraging findings, this review closes by sharing perspectives about future directions for designing and using sonified biofeedback in balance and gait training, and opportunities for more cohesive growth in this practice. One such suggestion is to pursue sonified designs and experimental designs that can translate to the neurorehabilitation field. This includes strategically selecting control groups and evaluation tasks to understand if improvements from training with one task transfer to additional relevant movement tasks. Additionally, it is important that future publications share details about the design processes and sound designs so researchers can more readily learn from one another.

CONCLUSIONS

Overall, this review shares the positive impact of using sonified biofeedback in balance and gait training. This review highlights the evidence of existing successes and potential for even more impactful future positive effects from using sonified biofeedback to help diverse populations with a spectrum of balance and mobility challenges and goals.

Osteoarthritis year in review 2023: Biomechanics

Biomechanics plays a significant yet complex role in osteoarthritis (OA) onset and progression. Identifying alterations in biomechanical factors and their complex interactions is critical for gaining new insights into OA pathophysiology and identification of clearly defined and modifiable mechanical treatment targets. This review synthesized biomechanics studies from March 2022 to April 2023, from which three themes relating to human gait emerged: (1) new insights into the pathogenesis of OA using computational modeling and machine learning, (2) technology-enhanced biomechanical interventions for OA, and (3) out-of-lab biomechanical assessments of OA. We further highlighted future-focused areas which may continue to advance the field of biomechanics in OA, with a particular emphasis on exploiting technology to understand and treat biomechanical mechanisms of OA outside the laboratory. The breadth of studies included in this review highlights the complex role of biomechanics in OA and showcase numerous innovative and outstanding contributions to the field. Exciting cross-disciplinary efforts integrating computational modeling, mobile sensors, and machine learning methods show great promise for streamlining in vivo multi-scale biomechanics workflows and are expected to underpin future breakthroughs in the understanding and treatment of biomechanics in OA.

Effects of biofeedback on biomechanical factors associated with chronic ankle instability: a systematic review with meta-analysis

BACKGROUND

Biofeedback may alter the biomechanics of lower extremities in patients with chronic ankle instability (CAI). We aimed to systematically review the literature on the effect of gait-training and biofeedback on biomechanical parameters in individuals with CAI and conduct a meta-analysis.

METHODS

We searched four databases including PubMed, Web of Science, Scopus and Embase from their inception through 30th June 2022. The Downs and Black appraisal scale was applied to assess quality of included studies. Two reviewers screened studies to identify those reporting the effect of biofeedback on biomechanical factors associated with CAI. Outcomes of interest were kinetics and kinematics. Two authors separately extracted data from included studies. Data of interest were study design, number of sessions, intervention, tools, outcomes, number, sex, age, height, and body mass of participants.

RESULTS

Thirteen studies with a total of 226 participants were included. Biofeedback was capable of shifting center of pressure (COP) and lateral plantar pressure medially and reducing foot inversion, adduction, propulsive vertical ground reaction force (vGRF), ankle joint contact force, peak pressure and pressure time integral in the lateral mid-foot and forefoot. Auditory biofeedback had agreater impact on modifying plantar pressure in individuals with CAI. The meta-analyses revealed that visual biofeedback reduces peak pressure in lateral mid-foot and pressure time integral at lateral and medial heel and pressure increases under the hallux.

CONCLUSION

Biofeedback can alter pressure, vGRF, and foot inversion associated with CAI. Auditory biofeedback had greater impact on modifying plantar pressure in individuals with CAI. Further studies are required to assess the prolonged effect and clinical consequences of biofeedback or a combination of feedback on CAI in different age groups. Moreover, developing a low-cost and user-friendly device that can be evaluated in high quality RCTs is important prior to implementing the intervention in the clinical setting to reduce symptoms of CAI.

Within-session and between-session effects of auditory biofeedback training on center of pressure location during gait in patients with chronic ankle instability

OBJECTIVES

To establish preliminary gait training dosage parameters for patients with chronic ankle instability (CAI) by determining the within-session and between-session effects of auditory biofeedback training on center of pressure (COP) location during gait.

DESIGN

Observational Longitudinal.

SETTING

Laboratory.

PARTICIPANTS

19 participants with CAI, 8 participants who did not receive auditory biofeedback (NoFeedback group) and 11 participants who did receive auditory biofeedback (AuditoryFeedback group) over an 8-session 2-week intervention.

MAIN OUTCOME MEASURES

COP location was measured at the start and at each 5-min interval during treadmill walking across all eight 30-min training sessions.

RESULTS

The AuditoryFeedback group had significant within-session lateral-to-medial shifts in COP location during only session-1 at the 15-min (45% of stance; peak mean difference = 4.6 mm), 20-min (35% and 45%; 4.2 mm), and 30-min time intervals (35% and 45%; 4.1 mm). Furthermore, the AuditoryFeedback group had significant between-session lateral-to-medial shifts in COP location at session-5 (35-55% of stance; 4.2 mm), session-7 (35%-95%; 6.7 mm), and session-8 (35%-95%; 7.7 mm). The NoFeedback group had no significant changes in COP location within-sessions or between-sessions.

CONCLUSIONS

Participants with CAI who received auditory biofeedback during gait needed an average of 15-min during session-1 to meaningfully shift their COP location medially and 4-sessions before retaining the adapted gait pattern.