Reliance on visual information after stroke. Part II: effectiveness of a balance rehabilitation program with visual cue deprivation after stroke: a randomized controlled trial1


      Bonan IV, Yelnik AP, Colle FM, Michaud C, Normand E, Panigot B, Roth P, Guichard JP, Vicaut E. Reliance on visual information after stroke. Part II: Effectiveness of a balance rehabilitation program with visual cue deprivation after stroke: a randomized controlled trial. Arch Phys Med Rehabil 2004;85:274–8.


      To test the hypothesis that balance rehabilitation with visual cue deprivation improves balance more effectively than rehabilitation with free vision.


      Single-blind, randomized controlled trial.


      Public rehabilitation center in France.


      Twenty patients with hemiplegia after a single-hemisphere stroke that occurred at least 12 months before the study.


      Patients were randomly assigned to 1 of 2 balance rehabilitation programs—with and without visual cue deprivation. In all other respects, the programs were identical. Each lasted for 1 hour and was implemented 5 days a week for 4 weeks. All patients completed the program.

      Mean outcome measures

      Balance under 6 sensory conditions was assessed by computerized dynamic posturography (EquiTest), gait velocity, timed stair climbing, and self-assessment of ease of gait before and after program completion.


      After completing the program, balance, gait velocity, and self-assessment of gait improved significantly in all patients. The improvements in gait velocity (P=.03) and timed stair climbing (P=.01) correlated significantly with improved balance. Balance improved more in the vision-deprived group than in the free-vision group.


      Balance improved more after rehabilitation with visual deprivation than with free vision. Visual overuse may be a compensatory strategy for coping with initial imbalance exacerbated by traditional rehabilitation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hesse S.
        • Jhanke M.
        • Schreiner C.
        • Mauritz K.H.
        Gait symmetry and functional walking performance in hemiparetic patients prior to and after a 4-week rehabilitation program.
        Gait Posture. 1993; 1: 166-171
        • Engardt M.
        • Ribbe T.
        • Olsson E.
        Vertical ground reaction force feedback to enhance stroke patients’ symmetrical body-weight distribution while rising/sitting down.
        Scand J Rehabil Med. 1993; 25: 41-48
        • Hocherman S.
        • Dickstein R.
        • Pillar T.
        Platform training and postural stability in hemiplegia.
        Arch Phys Med Rehabil. 1984; 65: 588-592
        • Lee M.Y.
        • Wong M.K.
        • Tang F.T.
        • Cheng P.T.
        • Lin P.S.
        Comparison of balance responses and motor patterns during sit-to-stand task with functional mobility in stroke patients.
        Am J Phys Med Rehabil. 1997; 76: 401-410
        • Walker C.
        • Brouwer B.J.
        • Culham E.G.
        Use of visual feedback in retraining balance following acute stroke.
        Phys Ther. 2000; 80: 886-895
        • Cheng P.T.
        • Wu S.H.
        • Liaw M.Y.
        • Wong A.M.
        • Tang F.T.
        Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention.
        Arch Phys Med Rehabil. 2000; 82 ([see comments]): 1650-1654
        • Geiger R.A.
        • Allen J.B.
        • O’Keefe J.
        • Hicks R.R.
        Balance and mobility following stroke.
        Phys Ther. 2001; 81: 995-1005
        • Sackley C.M.
        • Lincoln N.B.
        Single blind randomized controlled trial of visual feedback after stroke.
        Disabil Rehabil. 1997; 19: 536-546
        • Winstein C.J.
        • Gardner E.R.
        • McNeal D.R.
        • Barto P.S.
        • Nicholson D.E.
        Standing balance training.
        Arch Phys Med Rehabil. 1989; 70: 755-762
        • Visintin M.
        • Barbeau H.
        • Korner-Bitensky N.
        • Mayo N.E.
        A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation.
        Stroke. 1998; 29: 1122-1128
        • Sharp S.A.
        • Brouwer B.J.
        Isokinetic strength training of the hemiparetic knee.
        Arch Phys Med Rehabil. 1997; 78: 1231-1236
        • Duncan P.
        • Richards L.
        • Wallace D.
        • et al.
        A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke.
        Stroke. 1998; 29: 2055-2060
        • Richards C.L.
        • Malouin F.
        • Wood-Dauphinee S.
        • Williams J.I.
        • Bouchard J.P.
        • Brunet D.
        Task-specific physical therapy for optimisation of gait recovery in acute stroke patients.
        Arch Phys Med Rehabil. 1993; 74: 612-620
        • Dean C.M.
        • Richards C.L.
        • Malouin F.
        Task-related circuit training improves performance of locomotor tasks in chronic stroke.
        Arch Phys Med Rehabil. 2000; 81: 409-417
        • Teixeira-Salmela L.F.
        • Olney S.J.
        • Nadeau S.
        • Brouwer B.
        Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors.
        Arch Phys Med Rehabil. 1999; 80: 1211-1218
        • Rode G.
        • Tilikete C.
        • Harlopain P.
        • Boisson D.
        Postural asymmetry reduction by vestibular caloric stimulation in left hemiparetic patients.
        Scand J Rehabil Med. 1998; 30: 9-14
        • Perennou D.A.
        • Amblard B.
        • Leblond C.
        • Pelissier J.
        Biased postural vertical in humans with hemispheric cerebral lesions.
        Neurosci Lett. 1998; 252: 75-78
        • Bottini G.
        • Sterzi R.
        • Vallar G.
        • et al.
        Identification of the central vestibular projections in man.
        Exp Brain Res. 1994; 99: 164-169
        • Vallar G.
        • Lobel E.
        • Galati G.
        • Berthoz A.
        • Pizzamiglio L.
        • Le Bihan D.
        A fronto-parietal system for computing the egocentric spatial frame of reference in humans.
        Exp Brain Res. 1999; 124: 281-286
        • Perennou D.A.
        • Amblard B.
        • Laassel el M.
        • Benaim C.
        • Herisson C.
        • Pelissier J.
        Understanding the pusher behavior of some stroke patients with spatial deficits.
        Arch Phys Med Rehabil. 2002; 83: 570-575
        • Bonan I.V.
        • Colle F.M.
        • Guichard J.P.
        • et al.
        Reliance on visual information after stroke. Part I: Balance on dynamic posturography.
        Arch Phys Med Rehabil. 2004; 85: 268-273
        • Granger C.V.
        • Hamilton B.B.
        The Uniform Data System for Medical Rehabilitation report of first admissions for 1991.
        Am J Phys Med Rehabil. 1992; 71: 33-38
        • Fugl-Meyer A.R.
        • Jääskö L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic. 1. A method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Duvernoy H.M.
        The human brain. Springer, New York1991
        • Brandt T.
        • Dieterich M.
        • Danek A.
        Vestibular cortex lesions affect the perception of verticality.
        Ann Neurol. 1994; 35: 403-412
        • Hunt S.
        • McEwen S.
        Measuring health status.
        J R Coll Gen Pract. 1985; 35: 185-188
        • Nashner L.M.
        • Peters J.F.
        Dynamic posturography in the diagnosis and management of dizziness and balance disorders.
        Neurol Clin. 1990; 8: 331-349
        • Nashner L.M.
        • Black F.O.
        • Wall C.
        Adaptation to altered support and visual conditions during stance.
        J Neurosci. 1981; 2: 536-544
        • Black F.O.
        • Wall C.
        • Nashner L.M.
        Effects of visual and support surface orientation references upon postural control in vestibular deficient subjects.
        Acta Otolaryngol. 1983; 95: 199-210
        • Ford-Smith C.D.
        • Wyman J.F.
        • Elswick Jr, R.K.
        • Fernandez T.
        • Newton R.A.
        Test-retest reliability of the sensory organization test in noninstutionalized older adults.
        Arch Phys Med Rehabil. 1995; 76: 77-81
        • Coles M.G.
        • Gratton G.
        • Bashore T.R.
        • Eriksen C.W.
        • Donchin E.
        A psychophysiological investigation of the continuous flow model of human processing.
        J Exp Psychol. 1985; 11: 529-553
        • Friberg L.
        • Olsen T.S.
        • Roland P.E.
        • Paulson O.B.
        • Lassen N.A.
        Focal increase of blood flow in the cerebral cortex of man during vestibular stimulation.
        Brain. 1985; 108: 609-623
        • Ro T.
        • Cohen A.
        • Ivry R.B.
        • Rafal R.D.
        Response channel activation and the temporoparietal junction.
        Brain Cogn. 1998; 37: 461-476
        • Grüsser O.J.
        • Schreiter U.
        Localization and responses of neurons in the parieto-insular vestibular cortex of awake monkeys.
        J Physiol. 1990; 430: 537-557
        • Bottini G.
        • Karnath H.O.
        • Vallar G.
        • et al.
        Cerebral representations for egocentric space functional-anatomical evidence from caloric vestibular stimulation and neck vibration.
        Brain. 2001; 124: 1182-1196
        • Perennou D.A.
        • Leblond C.
        • Amblard B.
        • Micallef J.P.
        • Rouget E.
        • Pelissier J.
        The polymodal sensory cortex is crucial for controlling lateral postural stability.
        Brain Res Bull. 2000; 53: 359-365
        • Di Fabio R.P.
        • Badke M.B.
        Stance duration under sensory conflict conditions in patients with hemiplegia.
        Arch Phys Med Rehabil. 1991; 72: 292-295
        • Miyai I.
        • Mauricio R.L.
        • Reding M.J.
        Parietal-insular strokes are associated with impaired standing balance as assessed by computerized dynamic posturography.
        J Neurol Rehabil. 1997; 11: 35-40
        • Perennou A.P.
        • Leblond C.
        • Amblard B.
        • et al.
        Transcutaneous electric nerve stimulation reduces neglect-related postural instability after stroke.
        Arch Phys Med Rehabil. 2001; 82: 440-448
        • Rode G.
        • Tilikete C.
        • Harlopain P.
        • Boisson D.
        Postural asymmetry reduction by vestibular caloric stimulation in left hemiparetic patients.
        Scand J Rehabil Med. 1998; 30: 9-14
        • Andersen R.A.
        • Snyder L.H.
        • Li C.S.
        • Stricanne B.
        Coordinate transformations in the representation of spatial information.
        Curr Opin Neurobiol. 1993; 3: 171-176
        • Merfeld D.M.
        • Zupan L.
        • Peterka R.J.
        Humans use internal models to estimate gravity and linear acceleration.
        Nature. 1999; 398: 615-618
        • Dietz V.
        Human neuronal control of automatic functional movement.
        Phys Rev. 1992; 72: 33-69
        • Woollacott M.H.
        • Shumway-Cook A.
        • Nashner L.M.
        Ageing and postural control.
        Int J Ageing Hum Dev. 1986; 23: 97-114
        • Miltner W.
        • Bauder H.
        • Sommer M.
        • Dettmers C.
        • Taub E.
        Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke.
        Stroke. 1999; 30: 586-592
        • Nudo R.J.
        • Wise B.M.
        • SiFuentes F.
        • Milliken G.W.
        Neural substrate for the effects of rehabilitative training on motor recovery after ischemic infarct.
        Science. 1996; 272 (Comment in: Science 1996;272:1754): 1791-1794
        • Liepert J.
        • Bauder H.
        • Wolfgang H.R.
        • Miltner W.H.
        • Taub E.
        • Weiller C.
        Treatment-induced cortical reorganisation after stroke in humans.
        Stroke. 2000; 31: 1210-1216