Background <p>Step length asymmetry is a specific and persistent characteristic of hemiparetic gait in patients with chronic stroke, typically resulting from impaired weight bearing and reduced propulsive force on the paretic side. This asymmetry leads to reduced walking efficiency and an increased risk of musculoskeletal complications. This study investigated the efficacy of an anterioposterior weight-shift training (AP training) system utilizing visual biofeedback to improve gait asymmetry in patients with chronic stroke.</p> Methods <p>This randomized controlled trial enrolled 34 patients with chronic hemiplegic stroke who exhibited step-length asymmetry (step-length ratio &gt; 1.1). Participants were randomized into an AP training group or a control group. Both groups received conventional gait training for 6 weeks, and the experimental group received additional AP training sessions (30&#xa0;min, 3 times/week). The AP training system provided real-time visual biofeedback on the Center of Pressure trajectory and weight distribution. The primary outcome was the Step Length Asymmetry Index (SLAI). The secondary outcomes included plantar pressure distribution, temporospatial parameters, 3D kinematic/kinetic gait analysis, and energy consumption.</p> Results <p>The AP training group demonstrated significant improvements in the SLAI compared with the control group (<i>p</i> &lt; 0.05). Significant between-group differences favoring the intervention were also observed for swing time asymmetry, forefoot contact area, and pressure (<i>p</i> &lt; 0.05). Three-dimensional gait analysis revealed an increased ankle dorsiflexion angle and hip extension moment on the affected side in the training group. While the self-selected walking speed showed no significant difference, the maximum safe walking speed significantly improved in the training group (<i>p</i> &lt; 0.05). No significant between-group differences were observed in energy consumption (oxygen cost or oxygen rate).</p> Conclusion <p>AP training may effectively improve step length asymmetry and paretic limb mechanics in patients with chronic stroke. By enhancing the anterior weight transfer and propulsive force, this intervention offers a targeted strategy for addressing established asymmetric gait patterns in the chronic phase of recovery.</p> <p><i>Trial details</i> ClinicalTrial.gov Identifier NCT02207933.</p>