Visual and visual-proprioceptive training improve gait via sensory reweighting after chronic stroke: a randomized...

BACKGROUND: Post-stroke gait recovery depends on multisensory integration, but vision- and gaze-stability training are rarely emphasized. We tested whether 12-week visual oculomotor training (VOT) or visual–proprioceptive integration (VPI) programs improve gait after chronic stroke. METHODS: In this single-center, assessor- and analyst-blinded randomized controlled trial, 45 participants were allocated to a control group (CG), VOT, or VPI. All groups received standardized gait training plus three 30-min group-specific sessions weekly for 12 weeks. Static and dynamic visual acuity were assessed at baseline and post-intervention. Pre- and post-intervention, all participants completed 10-meter walk tests, during which data were synchronously acquired using a 3D motion-capture system (Qualisys) and dual force plates (Kistler). The primary outcome was comfortable gait speed measured during the 10-meter walk tests; secondary outcomes included step-length symmetry (SLS), center-of-pressure symmetry ratio (COP-SR), other spatiotemporal, kinematic, and kinetic gait measures, and clinical scales including the Fugl–Meyer Assessment–Lower Extremity (FMA-LE) and Berg Balance Scale (BBS). Between-group effects were estimated using baseline-adjusted ANCOVA. RESULTS: For the primary endpoint of comfortable gait speed, VPI improved significantly more than CG (P = 0.018), whereas VOT did not differ from CG or VPI (P = 0.284 and 0.142). Within groups, gait speed increased significantly only in VPI (P = 0.019; CG: P = 0.214; VOT: P = 0.184). For the key secondary outcome of SLS, VPI improved more than CG and VOT (P < 0.001 and P = 0.008, respectively), while VOT did not differ from CG (P = 0.224). The COP-SR shifted toward symmetry in all groups, but between-group differences were not significant (all P > 0.44), whereas paretic-limb COP displacement increased significantly only in VOT and VPI (P = 0.021 and 0.009, respectively). Both interventions produced significant within-group improvements in dynamic visual acuity and lower-limb motor function (ΔlogMAR and FMA-LE; all P < 0.05 for VOT and VPI, P > 0.10 for CG). BBS scores increased significantly in the intervention groups but not in CG, whereas between-group differences in BBS change were not significant (P = 0.153). Spatiotemporal analyses showed shorter cycle time, longer non-paretic and paretic step length, reduced double-limb support, and increased paretic single-limb support in VOT and VPI (all P < 0.05 vs. baseline), with no significant changes in CG (P ≥ 0.05). CONCLUSIONS: On top of conventional care, visual training targeting gaze stability and multisensory integration produced clinically relevant improvements in gait after chronic stroke. VPI produced the largest gains in gait speed and symmetry, supporting vision–vestibular–proprioceptive integration as a pragmatic rehabilitation target. Trial registration: Clinical Trial Registry: ChiCTR2500114339. Registered on 10 December 2025. Retrospectively registered.