Enhancing Physiotherapy Outcomes Through Multimodal Interventions in Post-Stroke Rehabilitation

Post-stroke rehabilitation integrates technological feedback systems to enhance motor relearning and autonomic regulation. Among these, physiological biofeedback—based on electromyography (EMG), heart rate variability (HRV) and electrocardiography (ECG)—represents a multimodal approach for restoring neuromotor control and autonomic balance. EMG biofeedback enables patients to visualize and voluntarily modulate muscle activation, supporting cortical reorganization and improving movement precision through real-time feedback. Recent meta-analyses confirm that EMG biofeedback significantly improves upper- and lower-limb function in stroke survivors, particularly when combined with task-oriented physiotherapy. EMG biofeedback demonstrates improvements in swallowing function, motor control, and patient motivation. Beyond the motor domain, HRV biofeedback has shown substantial benefits lately, especially in regulating the autonomic nervous system (ANS) activity, improving vagal tone, and reducing sympathetic overdrive: a major contributor to fatigue and cardiovascular instability post-stroke. By targeting the sympathetic–parasympathetic balance, HRV biofeedback not only enhances autonomic flexibility but also supports emotional and cognitive recovery. Together, these modalities integrate neuromuscular and autonomic rehabilitation, offering a path toward individualized, feedback-driven recovery protocols. This narrative review synthesizes recent evidence on the mechanisms, the clinical outcomes, and translational potential of EMG- and HRV-based biofeedback in stroke rehabilitation, highlighting their role in advancing physiotherapy toward an adaptive, data-driven, and neuroplastic paradigm, as from now on, the emerging directions will include integrating physiological biofeedback with immersive or AI-driven platforms for enhanced personalization and motivation.