Let’s collaborate to help connect the dots on the complexity of balance.


Patricia Winkler, Erica DeMarch, Heather Campbell, Marcia Smith,
Use of real-time multimodal sensory feedback home program improved backward stride and retention for people with Parkinson Disease: A pilot study, Clinical Parkinsonism & Related Disorders, Volume 6, 2022, 100132


• Multimodal sensory feedback with home exercises increased backward stride for PwPD.
• Retention of gains occurred 6 weeks after exercise ended for participants using MMSF.
• The MMSF home program improvements were likely due to integration of proprioception.
• Outcomes were highly rated by MMSF participants on a Perceived Outcome Scale.



Parkinson disease (PD) impairs sensory integration, contributes to motor dysfunction, loss of gait automaticity, and increased fall risk. Employing multimodal sensory feedback (MMSF) has the potential to improve proprioceptive integration and gait safety while reducing exercise burden especially for backward gait.


This single-blinded, randomized controlled pilot study used a home program with or without real-time visual, proprioceptive, and auditory feedback with stepping exercises which progressed in speed and distance. Both groups completed a six-week intervention followed by 6 weeks without exercise to assess long-term retention. Six additional weeks of exercises were completed to assess recovery of potential losses after the washout session.

Eleven people with PD exercised with real-time MMSF and 7 exercised without MMSF. Outcome measures included backward stride length, velocity, cadence, and double support time. The Dual Timed Up and Go measured automaticity. Self-perceived improvements in gait, activities of daily living, participation, and quality of life were registered by a questionnaire.


Analysis was by repeated measures ANOVA. Using MMSF significantly improved backward stride length at 12 and 18 weeks, p = .007, η2 = 0.239. Both groups improved in all outcome measures after the initial 6-week exercise program, supporting efficacy of stepping exercises. The MMSF + ex group's significant improvements after a 6-week washout supported automaticity development. Questionnaire items received higher agreement percentages from MMSF + ex participants.


Using real-time MMSF in a home program for pwPD provided significant and lasting improvements in backward stride, and potentially decreased fall risk and exercise burden compared to the same program without MMSF.

Balance Educational Handouts:

How you Balance Handout-Connecting the Different Systems

Reliable resources, articles, books and associations are listed as a reference promoting exercise and balance.

Falls prevention for the older adult

Check your risk for falling

Home Safety Tips

    Balance, Dizziness and Vertigo

    National and Local Organizations:

    Parkinson’s Disease

    Brain Injury

    Multiple Sclerosis



    Below are some of our favorite research articles that relate to our current assessment and treatment philosophy regarding multisensory feedback and Balance Matters. 


    NPR- Hidden Brain - When Everything Clicks: The Power Of Judgment-Free Learning 

    Research Citations:

    Avanzino L, Pelosin E, Vicario CM, Lagravinese G, Abbruzzese G, Martino D. Time Processing and Motor Control in Movement Disorders. Front Hum Neurosci. 2016;10:631. Published 2016 Dec 12. doi:10.3389/fnhum.2016.00631

    Baram Y, Aharon-Peretz J, Badarny S, Susel Z, Schlesinger I. Closed-loop auditory feedback for the improvement of gait in patients with Parkinson's disease. J Neurol Sci. 2016 Apr 15;363:104-6. doi: 10.1016/j.jns.2016.02.021. Epub 2016 Feb 10.

    Baram Y1, Miller A. Auditory feedback control for improvement of gait in patients with Multiple Sclerosis. J Neurol Sci. 2007 Mar 15;254(1-2):90-4. Epub 2007 Feb 20.

    Cha, Yong-Jun & Kim, Jung-Doo & Choi, Yu-Ran & Kim, Nan-Hyang & Son, Sung Min. (2018). Effects of gait training with auditory feedback on walking and balancing ability in adults after hemiplegic stroke: A preliminary, randomized, controlled study. International Journal of Rehabilitation Research. 41. 1. 10.1097/

    Chiviacowsky, S., & Wulf, G. (2007). Feedback after good trials enhances learning. Research Quarterly for Exercise and Sport, 78, 40–47

    Dozza M, Horak FB, Chiari Auditory biofeedback substitutes for loss of sensory information in maintaining stance.Exp Brain Res. 2007 Mar; 178(1):37-48.

    Ghai S. Effects of Real-Time (Sonification) and Rhythmic Auditory Stimuli on Recovering Arm Function Post Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2018;9:488. Published 2018 Jul 13. doi:10.3389/fneur.2018.00488

    Guadagnoli, M. A., & Lee, T. D. (2004). Challenge point: A framework for conceptualizing the effects of various practice conditions in motor learning. Journal of Motor Behavior, 36(2), 212–224.

    Horak, F. B. (2009). Postural compensation for vestibular loss. In Annals of the New York Academy of Sciences (Vol. 1164, pp. 76-81). (Annals of the New York Academy of Sciences; Vol. 1164

    Huang, H., Wolf, S. L., & He, J. (2006). Recent developments in biofeedback for neuromotor rehabilitation. Journal of Neuroengineering and Rehabilitation, 3(1), 1–12.

    Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of speech, language, and hearing research. 2008;51(1):S225-39

    Molier, B., Van Asseldonk, E., Hermens, H., & Jannink, M. (2010). Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review. Disability and Rehabilitation, 32(22), 1799–1809.

    Park JH, Chung Y. The effects of providing visual feedback and auditory stimulation using a robotic device on balance and gait abilities in persons with stroke: a pilot study. Physical Therapy Rehabilitation Science. 2016;5(3):125-131. doi:10.14474/ptrs.2016.5.3.125

    Pitale JT, Bolte JH. A heel-strike real-time auditory feedback device to promote motor learning in children who have cerebral palsy: a pilot study to test device accuracy and feasibility to use a music and dance-based learning paradigm. Pilot and Feasibility Studies. 2018;4:42

    Posada-Gómez R1, Montaño-Murillo RA, Martínez-Sibaja A, Alor-Hernández G, Aguilar-Lasserre AA, Reyes-Fernández MC. An Interactive System for Fine Motor Rehabilitation. Rehabil Nurs. 2018 Mar/Apr;43(2):116-124Ranganathan, R., & Newell, K. M. (2009). Influence of augmented feedback on coordination strategies. Journal of Motor Behavior, 41(4), 317–330

    Ribeiro, D. C., Sole, G., Abbott, J. H., & Milosavljevic, S. (2011). Extrinsic feedback and management of low back pain: A critical review of the literature. Manual Therapy, 16(3), 231–239.

    Ronsse, R., Puttemans, V., Coxon, J. P., Goble, D. J., Wagemans, J., Wenderoth, N., & Swinnen, S. P. (2011b). Motor learning with augmented feedback: Modality-dependent behavioral and neural consequences. Cerebral Cortex, 21(6), 1283–1294.

    Schaffert N, Janzen TB, Mattes K, Thaut MH. A Review on the Relationship Between Sound and Movement in Sports and Rehabilitation. Front Psychol. 2019;10:244. Published 2019 Feb 12. doi:10.3389/fpsyg.2019.00244

    Schenck C, Kesar TM. Effects of unilateral real-time biofeedback on propulsive forces during gait. Journal of NeuroEngineering and Rehabilitation. 2017;14:52

    Schmitz G, Bergmann J, Effenberg AO, Krewer C, Hwang TH, Müller F. Movement Sonification in Stroke Rehabilitation. Front Neurol. 2018;9:389. Published 2018 Jun 1. doi:10.3389/fneur.2018.00389

    Shea, C. H., & Wulf, G. (1999). Enhancing motor learning through external-focus instructions and feedback. Human Movement Science, 18(4), 553–571

    Shull PB, Damian DD. Haptic wearables as sensory replacement, sensory augmentation and trainer – a review. Journal of NeuroEngineering and Rehabilitation. 2015;12:59. doi:10.1186/s12984-015-0055-z.

    Sigrist, R., Rauter, G., Riener, R. et al. Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review. Psychon Bull Rev (2013) 20: 21

    Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation. Manual Therapy, 15, 19–25.

    Tzetzis, G., Votsis, E., & Kourtessis, T. (2008). The effect of different corrective feedback methods on the outcome and self confidence of young athletes. Journal of Sports Science and Medicine, 7, 371–378.

    Van Vugt FT1, Tillmann B2. Auditory feedback in error-based learning of motor regularity. Brain Res. 2015 May 5;1606:54-67. doi: 10.1016/j.brainres.2015.02.026. Epub 2015 Feb 23.