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Study selection
The main literature search yielded a total of 271 items from which 144 items remained after duplicate removal: PubMed (46 studies), Web of Science (68), Scopus (107) and Embase (50). We excluded 133 studies due to not meeting the inclusion criteria and included 11 studies after screening the titles and abstracts for further eligibility check. Two studies were added by hand search of reference list of included studies [25, 26], leading to a total of 13 included studies [1, 2, 4, 5, 7, 8, 13, 16, 21, 24, 25, 27, 28]. Figure 1. shows the flow diagram of the selection process and number of excluded studies at each stage.
Flow diagram of study selection process
Study characteristics
Table 2. summarizes the characteristics of the included studies. The designs of the included studies consisted of 2 RCTs (level-2 evidence) [3, 14] and 11 cross-sectional studies (level-3) [1, 2, 4, 5, 8, 13, 16, 21, 24, 25, 28]. The total sample size of included studies were 226.
Quality assessment
Table 3. shows the results of quality assessment using Downs and Black scale. The average score of eligible studies was 23.5 for RCTs and 13.36 for other studies. There were two studies with high quality (the RCTs) which had concealed allocation and similar participants at baseline [3, 14], and 11 studies with moderate quality [1, 2, 4, 5, 8, 13, 16, 21, 24, 25, 28].
Instrumentation
Five studies used vibration feedback from a force sensing resistor [25, 26, 28,29,30], Two studies used a novel device made of tracks and elastic bands and pedar-x plantar pressure system [27, 31], one study used real-time video and pedar-x system [16], two studies used a laser and pedar-x [15] or pressure mat [14], two studies utilized a buzzer connected to pedar-x system and flexi-foce load sensors [3, 17], and one study used both visual and auditory feedback using pedar-x and flexi-force load sensors with a laser or buzzer for feedback [6].
Task
The task in all studies was walking [1, 2, 4, 5, 7, 8, 13, 16, 21, 24, 25, 27, 28] except for one study which included static balance, step down, lateral hop and forward lounge [6]. Two studies assessed balance along with gait-training [25, 26].
Outcome measured
Of the 13 studies, 7 targeted plantar pressure [3, 6, 15,16,17, 31, 32], 8 measured COP [3, 6, 15, 25, 26, 28, 32], 2 targeted vGRF [26, 30], 3 targeted ankle 3D kinematics [14, 25, 29] and 1 measured maximum ground reaction force and the probable direction of that force [3].
Effect of novel gait-training device
Two studies [27, 31] assessed plantar pressure on the lateral region of the foot in CAI patients during a medially directed force to the lower leg via elastic bands at participant’s shank in a single [27] and 5-session [31] trial. The elastic bands were tied on two parallel tracks between participant ‘s shanks on a treadmill. Both studies [27, 31] reported a decreased pressure on the lateral column of the foot following gait training. COP was shifted significantly medially for all 10 comparisons during the stance phase (p < 0.003 with large effect sizes for all comparisons) [27].
Effect of vibration biofeedback
Five studies evaluated vibration biofeedback [25, 26, 28,29,30]. Three of the five studies investigated COP location during gait-training in laboratory and real-world [25, 26, 28]. A Force Sensing Resistor was applied under the lateral foot which delivered a vibration stimulus to the lateral malleolus in case of incorrect foot position. Instructions were given to “walk so you do not get the vibration.” COP data were obtained at baseline, posttest, and retention (after 2-minutes of walking). After laboratory training, COP position shifted medially. In phases 2–9 of stance phase (stance phase divided to 10), the COP was more medial at posttest and retention. In Real-world training, COP was more medial for phases 1–7 and retention measures were more medial in phases 1–6 [28]. vGRF LR decreased after laboratory gait retraining [26]. In another study [29] after lab training the ankle and forefoot were more abducted. After real-world training, the ankle and forefoot were more everted and more abducted. Propulsive vGRF and ankle JCF decreased in the second 50% of stance phase during the early and late adaptation phases [30].
Effect of visual biofeedback
Figures 2, 3, 4, and 5 shows the results of the meta-analysis with moderate evidence suggesting a significant decrease in pressure time integral in medial and lateral heel and peak pressure in total foot and lateral midfoot and a significant increase in hallux [15, 16]. However, only 2 studies were eligible for meta-analysis. Therefore, more studies are required to support these results.
Results of meta-analysis. (Peak pressure)
Results of meta-analysis. (Peak contact area)
Results of meta-analysis. (Peak contact time)
Results of meta-analysis. (Peak time integral)
Four of 13 studies assessed various methods of visual-biofeedback. Three studies investigated the visual-biofeedback on gait [14,15,16]. In one study [15], a laser pointer on shoes which is clinically available, projected a cross-line laser on the wall. Participants were told to keep the crossline of the laser projection in an up and down position in a single session of walking. The other study [16] provided a single-session-real time video of the participants own feet on the television in front of them and instructed them to “walk in a manner where you can no longer view the outside or inside of your foot on the television screen while you walk”. Another study [14], used visual gait biofeedback generated by a computer. Control group walked on treadmill without biofeedback but received rehabilitation along with biofeedback group. Participants were instructed to avoid walking on the outside of their foot so as not to make the oval turn red and the threshold was progressively decreased each session.
One study assessed visual- and auditory-biofeedback on static balance step down, lateral hop and forward lounge [6]. Visual biofeedback was given via a crossline laser and the participants were instructed to keep the vertical laser line projected on the wall in line with a tape and limit the rotation of crossline.
Three studies investigated pressure [6, 15, 16] while the other study assessed lower extremity kinematics of pre and post 8-sessions of visual-biofeedback training [14].
Visual biofeedback reduced plantar pressure on lateral midfoot and forefoot and COP trajectory was shifted medially [15]. Ankle inversion decreased at initial contact and during the entire stride cycle immediately and at the follow-up time point [14]. During eyes-open static balance, the number of COP data points in the anterolateral foot quadrant reduced, simultaneously COP data points increased in the posteromedial quadrant. During a Lateral Hop, visual biofeedback increased peak pressure and pressure-time integral in the lateral heel and lateral mid-foot [6].
Effect of auditory biofeedback
Three studies assessed the effect of auditory biofeedback on gait in individuals with CAI [3, 6, 17]. These studies assessed the following outcomes: static balance, step down, lateral hop and forward lunge [6], pressure [6, 17] and COP [3]. The studies used a load sensor connected to a buzzer which elicits a noise with each step. The participants were told to walk in a manner that the device does not make a noise. Peak pressure in lateral mid-foot, forefoot and central-foot was reduced and EMG amplitudes increased in peroneus longus and medial gastrocnemius 200 milliseconds after initial contact [17].
Pressure and force was reduced in lateral foot and COP was shifted immediately and 1-week after intervention [3]. COP was reduced in the anterolateral quadrant and increased in the posteromedial quadrant of the foot during eyes-open balance. Lateral heel pressure and the lateral heel and midfoot pressure-time integral increased during the eyes-closed trials. Heel pressure increased during step downs and the lateral forefoot pressure-time integral decreased during lunges [6]..
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