Effectiveness of Laser Visual Feedback in Postural Control After a Stroke

Efectividad de Ejercicios Con Feedback Visual Mediante láser en el Control Postural en Usuarios Con Ictus Subagudo: un Ensayo clínico Aleatorizado

Background: Stroke is one of the leading causes of acquired disability and frequently results in impairments in balance and postural control that affect functional independence. Rehabilitation during the subacute phase is crucial for promoting neurological recovery. Visual feedback using a laser device may facilitate motor learning and postural correction; however, its effectiveness in individuals with subacute stroke has been insufficiently investigated.

Objectives: To evaluate the effectiveness of a laser-based visual feedback exercise program in improving postural control in individuals with subacute stroke. Secondary objectives are to assess its impact on balance, mobility, and functional performance, and to compare outcomes with those achieved through conventional rehabilitation.

Methods: A randomized controlled trial will be conducted in individuals with subacute stroke. Participants will be randomly assigned to either an intervention group, receiving exercises with laser-based visual feedback, or a control group, receiving usual rehabilitation care. Pre- and post-intervention assessments will be performed using validated instruments to measure postural control, balance, and functional capacity.

Discussion: This study addresses the need to identify effective, accessible, and low-cost therapeutic strategies to optimize post-stroke rehabilitation. If proven effective, laser-based visual feedback could enhance functional recovery, promote greater independence in activities of daily living, and help reduce the long-term impact of disability. The findings will provide scientific evidence relevant to clinical practice and may support the incorporation of this approach into neurological rehabilitation programs. In addition, the project will generate valuable knowledge for future research on innovative feedback-based strategies to improve functional recovery following stroke.

Background and Rationale

Subacute stroke is commonly associated with impairments in postural control, balance, and movement organization that directly limit functional recovery. Among these impairments, trunk control plays a central role, as it compromises the proximal stability required for maintaining sitting and standing positions, performing transfers, and generating effective motor responses. Therefore, postural control should not be viewed as an isolated rehabilitation goal, but rather as a fundamental basis for overall motor recovery. Likewise, recovery of trunk control has been linked to improvements in upper limb function, and interventions focused on proximal stabilization may enhance arm and hand performance. Taken together, these findings support the concept that optimizing postural control may facilitate both locomotor and manipulative function.

Several studies have shown that visual feedback can improve postural awareness and motor performance. However, evidence regarding the use of laser-based visual feedback in individuals after stroke remains limited. Existing studies have mainly focused on people with chronic stroke or those presenting with pusher syndrome, whereas evidence in the subacute phase is scarce. In particular, there is a lack of research involving participants who meet inclusion criteria similar to those proposed in the present study, namely individuals who are able to initiate standing with assistance. This places the project within a population with greater functional impairment that is currently underrepresented in the scientific literature.

To address this gap, a structured and progressive exercise program based on laser-guided visual feedback has been developed to improve postural control and balance in individuals with subacute stroke.

HYPOTHESES AND OBJECTIVES

Primary Hypothesis

The inclusion of a laser-based visual feedback exercise program as part of conventional physiotherapy treatment in individuals with subacute stroke improves balance.

Secondary Hypothesis

The inclusion of a laser-based visual feedback exercise program in addition to conventional treatment in hospitalized individuals with subacute stroke improves postural control, enhances gait parameters, increases upper-limb functional capacity, and reduces the risk of falls compared with individuals receiving conventional treatment alone.

Objectives

To design and validate laser-based visual feedback exercises aimed at improving balance in individuals with subacute stroke.

To evaluate whether the implementation of a laser-based visual feedback exercise program, in combination with conventional treatment, improves balance in individuals with subacute stroke.

Copilot said:

Study Design

A randomized controlled trial (RCT) will be conducted with two parallel groups (experimental and control) and single blinding of the assessor responsible for evaluating the effectiveness of the intervention. Both participants and investigators will be aware of group allocation.

Study Population

The study is aimed at individuals in the subacute phase of stroke. Procedure

All participants enrolled in the study will be admitted to the Pere Virgili Intermediate Care Hospital in Barcelona after having received care in an acute care hospital. Upon admission, participants will be immediately included in a multidisciplinary rehabilitation program tailored to their individual psychofunctional needs.

The Pere Virgili Intermediate Care Hospital provides several healthcare services, including inpatient care, outpatient care, and long-term care services. Within the inpatient setting, patients with stroke are admitted to the convalescence unit, where they receive a comprehensive rehabilitation-oriented approach. The average length of stay for these patients is approximately 38 days.

Regarding rehabilitation services, patients are assessed on the day of admission by each specialist professional involved in their care. Individuals with stroke receive five 30-minute occupational therapy sessions per week and five 30-minute physiotherapy sessions per week.

Each participant is assigned the same therapist from the initial assessment until completion of treatment. Rehabilitation is individualized according to each participant's deficits, previous functional status, and personal concerns. Physiotherapy combines traditional hands-on techniques, such as the Bobath and Perfetti approaches, with manual therapy, stretching, and massage therapy, together with motor learning-based interventions. These techniques aim to maintain joint range of motion, improve postural control and balance, and facilitate gait retraining.

Intervention Description

As participants are enrolled in the study, they will be randomly assigned to either the experimental group or the control group. Both groups will receive physiotherapy treatment five days per week for four weeks.

The control group will receive the center's usual care, as described above, consisting of 30-minute sessions. The experimental group will receive conventional physiotherapy treatment two days per week and a laser-based visual feedback exercise program three days per week, with each session lasting 30 minutes.

Following the provision of written informed consent, participants will be randomly assigned to one of the two study groups: the control group (CG) or the experimental group (EG).

Before the initiation of any intervention, participants will undergo a baseline assessment (T0). Subsequently, a follow-up assessment at 15 days (T1) and a final assessment at 30 days (T2) will be conducted.

All outcome variables will be assessed at baseline (T0) and at the end of the intervention (T2). Additionally, variables related to balance (S-PASS), as well as fall risk, balance, and gait (Tinetti Scale), will also be assessed at the intermediate 15-day visit (T1).

All assessments will be conducted by a single external assessor who will receive prior training in the administration and scoring of all outcome measures used in the study. The assessor will remain blinded to participants' group allocation throughout the study in order to minimize potential assessment bias.

Inclusion Criteria:

• Adults aged 18 years or older admitted from an acute care hospital to a convalescence, rehabilitation, or intermediate care unit for functional recovery following a stroke.
• Diagnosis of ischemic or hemorrhagic stroke confirmed by magnetic resonance imaging (MRI) or computed tomography (CT).
• Ability to tolerate assisted standing for a minimum of 10 seconds.
• Hemodynamically stable individuals, free from fever and disabling pain

Exclusion Criteria:

• Severe pre-stroke functional dependency, defined as a Barthel Index (BI) score ≤ 60.
• Diagnosis of dementia with a score ≥ 4 on the Global Deterioration Scale (GDS).
• Spasticity assessed with the Modified Ashworth Scale (MAS) ≥ 2.
• Diagnosis of acute confusional syndrome or delirium.
• Diagnosis of receptive aphasia (Wernicke's aphasia).
• Visual impairment that prevents the participant from following the laser beam used in the intervention.
• History of severe balance disorders or traumatic/orthopedic conditions that would prevent participation in the proposed rehabilitation treatment.
• Absence of balance impairment, defined as a Postural Assessment Scale for Stroke Patients (PASS) score ≥ 24 points.