Page 1
REVIEW ARTICLE
EFFECT OF AUGMENTED FEEDBACK ON MOTOR FUNCTION OF
THE AFFECTED UPPER EXTREMITY IN REHABILITATION PATIENTS:
A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS
Henk van Dijk1, Michiel J. A. Jannink1 and Hermie J. Hermens1,2
From the 1Roessingh Research and Development and 2Faculty of Electrical Engineering, Mathematics and Computer Science,
University of Twente, Enschede, The Netherlands
Objective: Assessment of the available evidence regarding
the effect of augmented feedback on motor function of the
upper extremity in rehabilitation patients.
Methods: A systematic literature search was performed to
identify randomized controlled trials that evaluated the
effect of augmented feedback on motor function. Two re-
viewers systematically assessed the methodological quality
of the trials. The reported effects were examined to evaluate
the effect of therapeutic interventions using augmented
feedback and to identify a possible relationship with patient
characteristics, type of intervention, or methodological
quality.
Results: Twenty-six randomized controlled trials were
included, 9 of which reported a positive effect on arm func-
tion tests. Follow-up measurements were performed in 8
trials, 1 of which reported a positive effect. Different thera-
peutic interventions using augmented feedback, i.e. electro-
myographic biofeedback, kinetic feedback, kinematic
feedback, or knowledge of results, show no difference in
effectiveness.
Conclusion: No firm evidence was found of effectiveness
regarding the use of augmented feedback to improve motor
function of the upper extremity in rehabilitation patients.
Future studies should focus more on the content, form and
timing of augmented feedback concerning the therapeutic
intervention. It should be emphasized that motor learning
effects can only be determined by re-examining the popu-
lation after a follow-up period.
Key words: biofeedback, knowledge of results, motor skills,
upper extremity, arm.
J Rehabil Med 2005; 37: 202–211
Correspondence address: H. van Dijk, Roessingh Research
and Development PO Box 310, 7500 AH Enschede, The
Netherlands. E-mail: h.vandijk@rrd.nl
Submitted July 5, 2004; accepted December 29, 2004
INTRODUCTION
Feedback, along with practice, is considered to be a potent
variable affecting motor skill learning (1, 2). When one performs
a task, there are 2 general types of performance-related infor-
mation, or feedback, available. One type of feedback is called
“task-intrinsic” (or inherent) feedback, which is the sensory-
perceptual information that is a natural part of performing a
skill. For example, a person sees that he has missed picking up
a cup with his hands. The second type of feedback is called
“augmented” feedback. Although various terms have been
used to identify this type of feedback (information, extrinsic
or artificial feedback), the term that will be used in this review
is augmented feedback. “Augmented” refers to adding to or
enhancing task-intrinsic feedback with an external source (2, 3).
The external source may be a therapist or a device such as
a biofeedback system or a timer. This review focuses on the
influence of augmented feedback on the performance and
learning of motor skills.
Augmented feedback has been the focus of a large body of
research (see Salmoni et al. (4) and Winstein (5) for reviews)
and provides a fundamental cornerstone for motor learning
theories. Substantial work has been conducted in which the
effects of feedback variations such as content, form and timing
have been studied (2, 3). Most of the research on which we base
our knowledge of augmented feedback comes from laboratory
experiments in which researchers gave augmented feedback
to young, healthy participants. Typical tasks involved in these
studies were simple and very contrived.
Augmented feedback, properly employed, may have practical
implications for rehabilitation therapy since the re-acquisition
of motor skills is an important part of functional motor recovery
(5, 6). Some patients with cognitive and perceptual impairments
are not able to use intrinsic feedback to guide their performance
(7). Furthermore, because their own abilities to generate
intrinsic feedback may be compromised by neurological sensory
impairments, they may be more dependent on augmented
feedback (8). However, a rehabilitation professional may find
it difficult to implement the motor learning principles due to
# 2005 Taylor & Francis. ISSN 1650-1977
DOI 10.1080/16501970510030165 J Rehabil Med 37
J Rehabil Med 2005; 37: 202–211
Page 2
problems with generalizing the laboratory-based motor learning
studies into a clinical setting (9).
Within the rehabilitation setting, therapeutic interventions are
often aimed at improving motor function of the upper extremity.
For example, loss of function of the affected upper extremity is a
major problem after stroke (10). Also, patients with Parkinson’s
disease experience persistent difficulties with motor function of
the upper extremity (11).
In recent decades, a number of articles have been published
in which the effect of various rehabilitation methods using
augmented feedback to improve arm function has been evalu-
ated. Apart from many clinical studies of varying designs,
several attempts have been made to synthesize the findings in
reviews and meta-analyses. Most of these focus on 1 specific
therapeutic intervention, such as EMG biofeedback (12–14).
However, the present review focussed on the augmented feed-
back underlying a diversity of therapeutic interventions.
This present systematic review was performed to address the
following research questions:
! What is the effect of therapeutic interventions using
augmented feedback on motor function of the affected upper
extremity in rehabilitation patients?
! Is there a relationship between the reported effects and
patient characteristics, type of intervention, or methodo-
logical quality?
METHODS
Computerized literature searches were performed using MEDLINE
(1966 – December 2004), EMBASE (1974 – December 2004), and
Cochrane Controlled Trials Register (Cochrane Library Issue 1, 2004).
The specialist rehabilitation research databases CIRRIE (Center for
International Rehabilitation Research Information and Exchange;
1990 – December 2004) and REHABDATA (1956 – December 2004)
were also searched. The CIRRIE database contains citations of inter-
national rehabilitation research. REHABDATA is an extensive database
of disability and rehabilitation literature abstracts. The following key
words were used: feedback, biofeedback, knowledge of results, re-
inforcement, cues, knowledge of performance, upper extremity, arm,
upper limb, rehabilitation. The MEDLINE search strategy is outlined
in Appendix 1. In addition, references to relevant publications were
hand-searched.
Two reviewers (HvD and MJAJ) screened the titles and abstracts of
the results of the literature searches independently. Trials that met the
following criteria were included in the review:
! Therapeutic intervention applied to improve the motor function of
the affected upper extremity in rehabilitation patients.
! Therapeutic intervention using augmented feedback.
! Outcomes measured at impairment and/or disability level.
! Randomized controlled trial (RCT).
! Published, full-length publication.
This systematic review only included RCTs because these are
considered to have the most robust study design with the least risk of
biased results. The reviewers did not apply any language restriction.
The publications that appeared to meet the inclusion criteria were
retrieved and full-length publications were reviewed in further detail. In
a consensus meeting, the 2 reviewers made the final decision on whether
or not a publication should be included in the final review. In cases of
disagreement, consensus was reached by discussion or, if necessary, by
consulting a third reviewer (HJH).
The methodological quality of each included trial was assessed. A
standardized quality scoring form (the Delphi list) containing 9 criteria
was used to assess the randomization, treatment allocation, compar-
ability between groups, eligibility criteria, blinding (of outcome assessor,
care provider and patient), point estimates and measures of variability,
and intention-to-treat analysis (see Appendix 2) (15). The 9 criteria could
be rated as “do not know” if the available information was unclear or
insufficient. If the available information was sufficiently clear, criteria
were rated as “yes”, indicating adequate methods, or “no”, indicating
inadequate methods or potential bias. Each “yes” was scored as 1 point,
and therefore, a maximum of 9 points was possible.
The 2 reviewers (HvD and MJAJ) independently extracted data
(methodological quality criteria, patient characteristics, type of inter-
vention, outcome measures, and reported effects in the original publi-
cations) using a structured form. Blinding of the reviewers was not
considered feasible because both reviewers already had considerable
knowledge of the literature included in the review. Any differences of
opinion were resolved by discussion or by the assistance of the third
reviewer (HJH). Tables describing the included trials were generated.
If necessary, trialists were contacted and requested to supply missing
data. Concerning the therapeutic intervention, 4 different types of
augmented feedback were reported: biofeedback, kinetic feedback,
kinematic feedback and knowledge of results. The term biofeedback
(BF) refers to an augmented form of feedback related to the activity
of physiological processes within the body such as muscle activity
(electromyographic (EMG) biofeedback) (2, 3). A detailed description
of the movement pattern or response dynamics requires kinetic and/or
kinematic feedback. Kinetic feedback parameters are obtained from the
units of mass, force and time and often include impulse and peak force
measures. Kinematic feedback parameters are derived from the dimen-
sions of length and time and common kinematic parameters include
displacement, velocity and acceleration values (16). Knowledge of
results (KR) is a score presented to the performer as a representation
of the outcome of the movement (2–4). This score often represented
the error discrepancy between the performer’s obtained response and
some externally defined goal, although it can also be a representation
of the actual outcome obtained.
The result of each trial was summarized as either “þ ” (positive
for the experimental group, p # 0.05) or “0” (no difference, p $ 0.05),
according to the results presented in the original publications. In case of
more than 1 reported effect (e.g. the experimental intervention consists
of more than 1 group) the reviewers selected the most relevant com-
parison of groups according to the research question. An attempt was
made to identify a relationship between reported effects and the
following variables: patient characteristics (different diagnoses), type of
intervention (different types of augmented feedback) and 2 methodo-
logical characteristics that have been shown to cause bias in the results of
earlier reviews (concealed allocation of treatment and blinding of the
outcome assessor) (17, 18).
RESULTS
The systematic search of the literature resulted in the identifi-
cation of 33 publications, 27 of which fulfilled the selection
criteria and were included in the present review (19–45). Six
publications were excluded because these trials were not ran-
domized. (A list of the excluded articles can be obtained on
request from the first author.) In the 27 publications included in
the review, 26 RCTs were described. The study characteristics
and the methodological scores rated by the present reviewers
are presented in Table I.
The number of patients included in a trial ranged from 9 (35)
to 132 (40, 41). In 18 trials (19–23, 25–28, 32, 33, 35, 37, 39–41,
43–45), the study population concerned stroke patients. Other
study populations were patients with traumatic brain injury
(TBI) (24, 37, 45), spinal cord injury (SCI) (29–31), Parkinson’s
disease (PD) (34, 36, 38) and cerebral palsy (CP) (42). Platz et al.
(36) used healthy subjects as controls.
J Rehabil Med 37
Effect of augmented feedback on motor function 203
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J Rehabil Med 37
204 H. van Dijk et al.
Page 4
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om
us
cu
la
r
st
im
ul
at
io
n
–
3
se
ss
io
ns
of
45
m
in
pe
r
w
k
fo
r
12
w
k
Fu
nc
ti
on
al
ab
il
it
ie
s
m
ea
su
re
;
m
an
ua
lm
us
cl
e
te
st
4
K
lo
se
et
al
.,
19
90
(3
0)
10
E
1 /
10
E
2 /
9E
3 /
10
C
SC
I
T
ot
al
:
?
(1
8–
45
)
T
ot
al
:
at
le
as
t
1
yr
E
1 :
E
M
G
B
F
an
d
co
nv
en
ti
on
al
th
er
ap
y
E
2 :
E
M
G
B
F
an
d
ne
ur
om
us
cu
la
r
st
im
ul
at
io
n
E
3 :
ne
ur
om
us
cu
la
r
st
im
ul
at
io
n
an
d
co
nv
en
ti
on
al
th
er
ap
y
–
3
d
pe
r
w
k
fo
r
16
w
k
C
on
ve
nt
io
na
l
th
er
ap
y
–
3
d
pe
r
w
k
fo
r
16
w
k
Se
lf
-c
ar
e
sc
or
e;
m
ob
il
it
y
sc
or
e;
m
an
ua
lm
us
cl
e
te
st
;
E
M
G
ac
ti
vi
ty
4
K
oh
lm
ey
er
et
al
.,
19
96
(3
1)
13
E
1 /
10
E
2 /
11
E
3 /
10
C
SC
I
E
1 :
38
(1
5)
/E
2
:
32
(1
8)
/
E
3 :
42
(1
5)
43
(1
8)
E
1 :
2.
8
w
k
(1
.0
)/
E
2 :
3.
2
(0
.9
)/
E
3 :
2.
5
(1
.0
)
3.
0
w
k
(0
.9
)
E
1 :
E
M
G
B
F
E
2 :
fu
nc
ti
on
al
el
ec
tr
ic
al
st
im
ul
at
io
n
E
3 :
E
M
G
B
F
an
d
fu
nc
ti
on
al
el
ec
tr
ic
al
st
im
ul
at
io
n
–
5
se
ss
io
ns
of
20
m
in
pe
r
w
k
fo
r
5–
6
w
k
C
on
ve
nt
io
na
l
th
er
ap
y
–
5
se
ss
io
ns
of
20
m
in
pe
r
w
k
fo
r
5–
6
w
k
Fu
nc
ti
on
sc
or
e
ev
al
ua
ti
on
;
m
an
ua
lm
us
cl
e
te
st
4
L
ee
et
al
.,
19
76
(3
2)
18
E
/1
8C
1 /
18
C
2 ;
cr
os
s-
ov
er
de
si
gn
St
ro
ke
64
(?
)
C
1
:
44
(?
)/
C
2 :
?
T
ot
al
:
56
.6
(3
1–
79
)
T
ot
al
:
6
w
k–
7
yr
E
M
G
B
F
–
20
co
nt
ra
ct
io
ns
of
5
se
c
C
1 :
pl
ac
eb
o
E
M
G
B
F
C
2 :
co
nv
en
ti
on
al
th
er
ap
y
–
20
co
nt
ra
ct
io
ns
of
5
se
c
E
M
G
ac
ti
vi
ty
3
L
um
et
al
.,
20
02
(3
3)
13
E
/1
4C
St
ro
ke
63
.2
(3
.6
)
65
.9
(2
.4
)
30
.2
m
o
(6
.2
)
28
.8
m
o
(6
.3
)
R
ob
ot
-a
ss
is
te
d
m
ov
em
en
t
tr
ai
ni
ng
–
24
se
ss
io
ns
of
1
h
ov
er
2
m
o
pe
ri
od
C
on
ve
nt
io
na
l
th
er
ap
y
–
24
se
ss
io
ns
of
1
h
ov
er
2
m
o
pe
ri
od
FI
M
T
M
(s
el
f-
ca
re
an
d
tr
an
sf
er
se
ct
io
ns
);
B
I;
FM
;
sh
ou
ld
er
an
d
el
bo
w
st
re
ng
th
;
re
ac
hi
ng
ab
il
it
y
5
J Rehabil Med 37
Effect of augmented feedback on motor function 205
Page 5
T
ab
le
I.
C
on
ti
nu
ed
R
ef
er
en
ce
Pa
ti
en
ts
D
ia
gn
os
is
A
ge
(y
ea
rs
)
M
ea
n
(S
D
)
T
im
e
po
st
-o
ns
et
M
ea
n
(S
D
)
In
te
rv
en
ti
on
–
du
ra
ti
on
O
ut
co
m
e
m
ea
su
re
sa
M
et
ho
do
-
lo
gi
ca
l
sc
or
e
E
xp
er
im
en
ta
l
gr
ou
p
C
on
tr
ol
gr
ou
p
E
xp
er
im
en
ta
l
gr
ou
p
C
on
tr
ol
gr
ou
p
E
xp
er
im
en
ta
l
gr
ou
p
C
on
tr
ol
gr
ou
p
M
ar
ch
es
e
et
al
.,
20
00
(3
4)
10
E
/1
0C
PD
65
.0
(5
.8
)
66
.9
(6
.3
)
T
ot
al
:
28
–
16
8
m
o
C
ue
d
ph
ys
ic
al
th
er
ap
y
–
3
se
ss
io
ns
of
1
h
pe
r
w
k
fo
r
6
w
k
N
on
-c
ue
d
ph
ys
ic
al
th
er
ap
y
–
3
se
ss
io
ns
of
1
h
pe
r
w
k
fo
r
6
w
k
U
PD
R
S
5
M
ro
cz
ek
et
al
.,
19
78
(3
5)
9E
/9
C
;
cr
os
s-
ov
er
de
si
gn
St
ro
ke
T
ot
al
:
?
(5
0–
75
)
T
ot
al
:
1–
10
yr
E
M
G
B
F
–
3
se
ss
io
ns
of
30
m
in
pe
r
w
k
fo
r
4
w
k
C
on
ve
nt
io
na
l
th
er
ap
y
–
3
se
ss
io
ns
of
30
m
in
pe
r
w
k
fo
r
4
w
k
A
ct
iv
e
R
O
M
;
E
M
G
ac
ti
vi
ty
3
Pl
at
z
et
al
.,
19
98
(3
6)
7E
1
/8
E
2 /
7C
1 /
8C
2
PD
E
1 :
65
.9
(8
.3
)/
E
2 :
62
.0
(1
4.
6)
C
1
:
62
.1
(1
3.
3)
/
C
2 :
60
.8
(1
5.
2)
E
1 :
7.
6
yr
(2
.6
)/
E
2 :
4.
3
(1
.8
)
H
ea
lt
hy
su
bj
ec
ts
as
co
nt
ro
ls
E
1 :
K
R
au
di
to
ry
rh
yt
hm
ic
cu
es
E
2
:
K
R
w
it
ho
ut
au
di
to
ry
rh
yt
hm
ic
cu
es
–
10
0
tr
ia
ls
C
1 :
K
R
w
it
h
au
di
to
ry
rh
yt
hm
ic
cu
es
C
2 :
K
R
w
it
ho
ut
au
di
to
ry
rh
yt
hm
ic
cu
es
–1
00
tr
ia
ls
E
nd
-p
oi
nt
ac
cu
ra
cy
;
to
ta
l
m
ov
em
en
t
ti
m
e;
m
ov
em
en
t
du
ra
ti
on
;
m
ax
im
um
ta
ng
en
ti
al
ac
ce
le
ra
ti
on
;
m
ax
im
um
de
ce
le
ra
ti
on
4
Pl
at
z
et
al
.,
20
01
(3
7)
20
E
1 /
20
E
2 /
20
C
St
ro
ke
an
d
T
B
I
E
1 :
49
(1
7.
9)
/
E
2 :
54
(1
8.
0)
58
.0
(1
5.
3)
E
1 :
6.
1
w
k
(3
.6
)/
E
2 :
6.
2
(7
.1
)
10
.3
w
k
(1
9.
9)
E
1 :
ar
m
ab
il
it
y
tr
ai
ni
ng
an
d
co
nv
en
ti
on
al
th
er
ap
y
E
2 :
K
R
,
ar
m
ab
il
it
y
tr
ai
ni
ng
,a
nd
co
nv
en
ti
on
al
th
er
ap
y
–
32
m
in
pe
r
w
kd
fo
r
3
w
k
(þ
co
nv
en
ti
on
al
th
er
ap
y)
C
on
ve
nt
io
na
l
th
er
ap
y
–
?
T
E
M
PA
;
ki
ne
ti
ca
ll
y
an
al
ys
is
of
ai
m
in
g
m
ov
em
en
ts
6
Sh
um
ak
er
,
19
80
(3
8)
10
E
/1
0C
PD
65
.2
(?
)
67
.2
(?
)
10
.7
yr
(?
)
12
.6
yr
(?
)
Fr
on
ta
l
E
M
G
B
F
an
d
pr
og
re
ss
iv
e
re
la
xa
ti
on
tr
ai
ni
ng
–
1
se
ss
io
n
pe
r
w
k
fo
r
15
w
k
N
o
tr
ea
tm
en
t
G
en
er
al
ap
ti
tu
de
te
st
ba
tt
er
y
(p
ar
ts
9
pl
ac
in
g
te
st
an
d
10
tu
rn
in
g
te
st
)
4
Sm
it
h,
19
79
(3
9)
6E
/5
C
St
ro
ke
55
.5
(4
0–
67
)
48
.6
(2
2–
67
)
23
.0
m
o
(7
–6
9)
12
.8
m
o
(6
–3
0)
E
M
G
B
F
–
2
se
ss
io
ns
of
1
h
pe
r
w
k
fo
r
6
w
k
C
on
ve
nt
io
na
l
th
er
ap
y
–
2
se
ss
io
ns
of
1
h
pe
r
w
k
fo
r
6
w
k
B
ru
nn
st
ro
m
’s
st
ag
es
of
re
co
ve
ry
;
au
di
o-
vi
su
al
fil
m
s
3
Su
nd
er
la
nd
et
al
.,
19
92
,
19
94
(4
1,
40
)
36
E
1 /
29
E
2 /
35
C
1 /
32
C
2
St
ro
ke
E
1 :
65
(3
2–
88
)/
E
2 :
67
(4
6–
92
)
C
1
:
68 (5
0–
82
)/
C
2 :
70
(3
5–
84
)
E
1 :
8
d
(2
–3
5)
/
E
2 :
9
(1
–3
1)
C
1 :
10
d
(2
–3
1)
/C
2 :
8
(0
–2
9)
E
1 :
en
ha
nc
ed
ph
ys
ic
al
th
er
ap
y
(i
nc
lu
di
ng
E
M
G
B
F)
–
se
ve
re
gr
ou
p
E
2
:
m
il
d
gr
ou
p
–
m
ed
ia
n
of
7
w
k
(0
–3
3)
of
in
pa
ti
en
t
th
er
ap
y;
m
ed
ia
n
of
11
w
k
(0
–5
0)
of
ou
tp
at
ie
nt
th
er
ap
y
C
1 :
co
nv
en
ti
on
al
th
er
ap
y
–
se
ve
re
gr
ou
p
C
2 :
m
il
d
gr
ou
p
–
m
ed
ia
n
of
4
w
k
(0
–4
8)
of
in
pa
ti
en
t
th
er
ap
y;
m
ed
ia
n
of
6
w
k
(0
–4
5)
of
ou
tp
at
ie
nt
th
er
ap
y
B
I;
Fr
en
ch
ay
ar
m
te
st
;9
ho
le
pe
g
te
st
;
E
M
I;
su
b-
te
st
s
of
th
e
m
ot
or
cl
ub
as
se
ss
m
en
t;
se
ns
or
y
lo
ss
;
pa
ss
iv
e
m
ov
em
en
t
an
d
pa
in
6
J Rehabil Med 37
206 H. van Dijk et al.
End of preview.
