EMG Biofeedback Training for a Mentally Retarded Individual with Cerebral Palsy


Electromyographic biofeedback training was used to facilitate finger and wrist extension movements in a mentally retarded individual with spastic hemiplegia. The client was a 29-year-old woman with profound mental retardation and cerebral palsy as a result of postnatal meningitis. During treatment, the client demonstrated a short attention span, lack of motivation, low frustration tolerance, and increased spasticity in her left hand. The client was able to hyperextend her fingers following finger extension training, although goniometric measurements showed a marked degree of wrist flexion and wrist ulnar deviation. Therefore, training was implemented to develop wrist extension movements. Biofeedback therapy resulted in a substantial increase in active wrist extension and a marked reduction in wrist ulnar deviation. Key Words: Biofeedback, Mental retardation, Cerebral palsy, Electromyography.

Uses of muscle biofeedback in the treatment of individuals with various neurological disorders are just beginning to be explored.1 The major thrust of neuromuscular reeducation has emphasized inhibi­ tion of spasticity, recruitment of motor unit activity, and muscle relaxation.2 For instance, EMG biofeed­ back has been used to develop inhibitory control of spastic gastrocnemius muscles,3 recruit tibialis ante­ rior muscle activity in paralytic foot-drop,4,5 and relax sternocleidomastoid muscle in spasmodic torticol­ lis. 6,7 Electromyographic biofeedback training has also been used to inhibit abnormal muscle synergy and restore normal synergy.8 This article reports the results of a study to determine the effectiveness of electromyographic biofeedback in facilitating finger and wrist extension movements in a mentally retarded individual with spasticity of wrist flexor muscles. METHOD The client was a 29-year-old woman who func­ tioned in the profound range of mental retardation. Her mental retardation and cerebral palsy (spastic left hemiparesis) was the result of postnatal menin­
Dr. Asato is Clinical Psychologist, Department of Psychology, San Antonio State Hospital/School, Box 23310, Highland Hills Station, San Antonio, TX 78223 (USA). Dr. Twiggs is Director, Rehabilitation Therapies, San Antonio State Hospital/School. Ms. Ellison is Director of Physical Therapy, Rehabilitation Therapies, San Antonio State Hospital/School. This article was submitted June 11, 1980, and accepted March 22, 1981.

gitis. Her mental age was 2.7 years with an IQ of 13 and she functioned at Level III on the Adaptive Behavior Scale. The client's expressive communica­ tion skills consisted of two- and three-word utterances (noun-verb combinations). Language receptive skills included performance of appropriate action following a simple verbal request, responding correctly and nonverbally to questions concerning physical condi­ tion (eg, "Are you tired?"), and demonstrating an awareness of positional concepts (eg, "up-down," "inout," "under-over"). The physical therapy assessment results indicated the left upper extremity position was characterized by shoulder adduction and internal rotation, elbow hyperextension, forearm pronation, wrist and finger flexion, and wrist ulnar deviation. Goniometric mea­ surements indicated 84 degrees wrist flexion, 66 de­ grees of wrist ulnar deviation, and full finger flexion. The thumb was "indwelling." Weakness and spastic­ ity were present in the left upper extremity: weakness was characterized by muscular atrophy in the hand and forearm, and spasticity was indicated by an es­ sentially nonfunctional clubbed hand. Calluses were also noted over the proximal interphalangeal joints of her left hand. These calluses were self-inflicted wounds we thought occurred because of the client's frustration and inability to use the affected limb. The only functional use of the left hand was giving occa­ sional assistance to the right extremity. The client received daily physical therapy at this institution for 35 weeks before biofeedback training. Goals of treatment were 1) to strengthen and increase

Volume 61 / Number 10, October 1981


The various therapeutic techniques implemented to initiate func­ tional nonsynergistic movements included 1) stimu­ lation of cutaneous receptors by light stroking and brushing. We found that an alternative method of treatment was indicated in our case. There were 13 training sessions with an average of 2 sessions a week. After this baseline session. the client was given verbal instructions for performing extensor movements ("Raise your hand") and was also provided with a model of the appropriate response. 3) passive exercise. Biofeedback Training: Finger Extension A 30-minute baseline session was conducted to determine whether the client could exhibit finger or wrist extensor movements without the occurrence of abnormal. In the remaining sessions (2-13) for finger extensor training. VT 05101. 2) encouragement of spontaneous explora­ tory movements of a relaxed extremity in relation to various objects situated around the individual. and no functional improvement was observed after 35 weeks of therapy. and low frustration tolerance during physical therapy. and 4) active assistive exercise. she was not able to demonstrate any wrist extension movements during the initial training session. lack of motivation. Myoelectric potentials were detected. Laramie. Bellows Falls. † Coulbourn Instruments.000 Hz). There was a total of 15 trials for each training session. Treatment of motor system dysfunction is guided by the principle that distal motor development follows proximal motor development. As a result of the client's short attention span. The client's inability to demonstrate any wrist extension responses may have been due to a marked degree of wrist ulnar deviation. filtered (90 to 1. spasticity in her left hand increased during treatment. Although the client's interest and motivation were quite noticeable." Biofeedback Apparatus Surface silver/silver chloride pregelled electrodes* were placed over the extensor digitorum communis muscle.9 Application of the proximodistal principle for an individual exhibiting weakness and spasticity in the hand means initiating wrist extension training before finger extension train­ ing. it was defined as a "spontaneous finger extensor re­ sponse. elbow flexion. The therapist also provided a model of the appropriate response by demonstrating wrist-finger extension.functional ability of left upper and left lower extrem­ ities and 2) to improve gait posture. Verbal instruc­ tions were accompanied by passive extension of the client's wrist and fingers in order to 1) demonstrate the biofeedback principle and 2) serve as a procedure for shaping the desired response. synergistic movements. the function of the biofeedback device was explained to the client by stating that music would be turned on if she displayed extension movements of her left hand. training sessions were conducted to determine the efficacy of biofeedback therapy in facilitating hand extensor movements. and 3) a noticeable increase in motivational level of the client after finger extension during the initial session of biofeedback training. because of several factors: 1) a significant amount (66°) of wrist ulnar deviation. The potentiometer was used to detect the presence of signals above a predetermined voltage. The following se­ quence of synergistic movements typically preceded finger extension: shoulder abduction. the remaining therapy sessions incorporated finger. (Skin-electrode impedance was measured 10 minutes after electrode application and found to be about 10k Ω. A threshold feedback program was devised by hav­ ing integrated muscle signals fed into a potentiometer. however. Although the client was profoundly mentally retarded. PHYSICAL THERAPY . she possessed a modicum of cognitive abil­ ities that made it possible for biofeedback training to be implemented in conjunction with regular physical therapy programing. the potentiometer acti­ vated a timer that determined the duration that an AC switch (optically isolated between system and * Vermont Medical Inc. extension training. To facilitate extensor move­ ments.) Muscle activity was monitored by a Model S75-01 Bioamplifier† operated in the EMG mode. a pillow was placed on the client's lap with her hands resting on top of the pillow and with open palms facing down. shoulder external rotation. The procedure of passively extending the client's wrist and fingers was not repeated after the initial training session because she demonstrated an understanding of the feedback principle: she was able to exhibit an exten­ sion response (of her fingers) after the verbal instruc­ tion ("Turn the music on!") and modeling cues were given. rectified. ampli­ fied. WY 82070. A motor response that occurred immediately after passive extension of the client's hand was not defined as an extension response initiated by the client. Whenever a signal was above threshold. Each session lasted about 30 minutes. the client was given a verbal cue ("Turn the music on!") and a modeling cue (therapist performing wrist-finger extensor response) as the method of ini­ tiating the appropriate response. At the beginning of the baseline session. and integrated. 2) a profound level of mental retardation. 1448 During the initial training session. forearm supination. Therefore. Rockingham Rd. Box 194. and not wrist. and elbow hyperextension. Biofeedback therapy was initiated to circumvent the motivational problems encountered in physical therapy and to provide a method of restoring upper extremity func­ tion. If finger extension occurred without any cues (verbal or modeling).

if the feedback timer was set for 10 seconds. Results: Finger Extension Training tiated by the client without the occurrence of synergistic movements. A = wrist and finger extension. the timer automatically reset itself and feedback continued for 10 more seconds. the threshold for feedback was increased (about 5 to 10 µV. and = wrist flexion and finger extension. However. Thus. Development of finger and wrist extensor responses as a function of neuromuscular reeducation in a hemiplegic mentally retarded individual. threshold for EMG activity was slowly increased as 1449 A baseline session was conducted to determine the frequency of wrist or finger extensor movements iniVolume 61 / Number 10. during most of the training sessions. At the beginning of biofeedback training. October 1981 .Figure. I = finger extension. a training program for coordinating EMG activity and feedback (music) was implemented by having an AC control provide an FM radio with 110 VAC. J = finger extension—verbal/modeling cues. If a training session began where the level of the extensor response was below the threshold level set for the previous session. sec so that minimal extensor movements could initiate the feedback process. For example. This procedure increased the probability of a weaker extensor response initiating feedback (FM music) and thus strengthened the response itself. As training progressed and as finger extension improved sufficiently.) load) supplied an external device (eg. A timer determined the duration of feedback whenever muscle activity was above threshold.sec above the resting EMG. the threshold for EMG activity on the potentiometer was lowered to a point about 5 to 10 µV.sec a session) so that a stronger extension response was required to initiate feedback. any EMG potentials above the preset threshold level (on the potentiometer) for 1. Whenever muscle activity was above threshold during the feedback period. threshold for EMG activity was set at approximately 30 µV.000 msec activated the timer and led to presentation of feedback for 10 seconds. the feedback recycled continuously for 10 second intervals. No wrist or finger extensor responses were observed during the baseline session. FM radio) with 110 V alternating current (VAC). If EMG activity remained above threshold level.

toys) with her left hand. A marked soften­ ing of the calluses on her proximal interphalangeal joints was noted and she began to initiate attempts to grasp objects (parallel bars. held hands with other patients to form a circle. In a study designed to assess the nature of attentional problems that impair performance. There are attentional deficits in mentally retarded individuals. Electrode placement for recording wrist extensor movements was the same as the placement used for recording finger extensor responses. The only instruction given to the client was "Turn the music on!" Whenever an exten­ sor response occurred with wrist flexion. Harrison and associates found that an auditory cue (music) facilitated manual dexterity in severely and PHYSICAL THERAPY . Finger extension was observed in all 15 trials: a 10 percent improvement in the response after wrist extension training. Verbal instructions were given to the client ("Turn the music on!") along with passive extension of the wrist to demonstrate the appropriate response. goniometric measurements showed that finger hyperextension was accompanied by 10 degree of wrist extension and 45 degrees of wrist ulnar deviation. In 80 percent of the probe trials (see Probe in Figure).) Biofeedback therapy resulted in a net increase of 94 degrees of active wrist extension and a reduction of 21 degrees of wrist ulnar deviation. the technician reported that the client started placing her extended left hand over the parallel bar (when she walked between them) and over textured surfaces (when she made horizontal movements with the hand). (Before biofeedback training. In later sessions. COMMENTS Muscle reeducation studies generally use feedback in both auditory and visual modalities. 1450 finger hyperextension was accompanied by wrist ex tension (0 to 10°). Krupski reported that retarded participants exhibited a greater degree of off-task glancing than nonretarded participants in a visual reaction-time task. This indicated a net increase in the client's ability to extend her wrist 32 degrees actively. Wrist Extension Training At the end of finger extension training.the client showed progressively greater improvement in extensor motor responses (Figure). extensor movements were accompanied by a marked degree of wrist flexion. One year following biofeedback training. Prior to therapy. The client was able to initiate extensor movements on all 15 probe trials without any cues (verbal or modeling). The client's hands were placed on top of a pillow with open palms facing down. The thumb re­ mained indwelling throughout therapy. On the remaining probe trials finger hyperextension was accompanied by wrist flex ion (52°). a probe (follow-up session) was conducted to determine the efficacy of training. During early training sessions the client occasion­ ally complained of soreness in her arm. In physical therapy. staff members commented that the client frequently demonstrated finger and wrist exten­ sor responses and appeared quite pleased that she could perform this movement. several members of other disciplines have reported that the client has attempted to make extensor hand move­ ments in various settings outside biofeedback therapy. During the initial training session.10 On the other hand. In dance therapy. goniometric measurements showed that hyperextension of the fingers was accompanied by 52 degrees of wrist flexion and 47 degrees of wrist ulnar deviation. the client ex­ hibited a great deal of confusion as a result of the change in the desired response (ie. the client was able to perform this extensor response without cues on 90 percent of the trials. however. To alleviate this condition. This training procedure to reduce wrist flexion was conducted for eight weeks (16 sessions). By the end of the sixth session. which appar­ ently reduced her motivation to respond. wrist extension as opposed to finger extension). In order to maintain the biofeedback setting as a pleasant and therapeutic environment. A therapist also modeled the appropriate response for the client. In the dormitory. training was implemented to develop wrist extensor movements. Results: Wrist Extension Training One month after the termination of wrist extension training. the client was able to hyperextend (15°) the metacarpophalangeal joints of her fingers on cue for all 15 trials without initiating any abnormal synergistic movements (Figure). and used her open left hand to pat her thigh. the therapist brought the wrist slowly and progressively into exten­ sion. the resting position of her metacarpo­ phalangeal joints was 95 degrees. doors. the remaining sessions were conducted without the new response demand (wrist extension) placed on the client. At the termination of finger extension training. These behaviors were observed frequently by the dance therapist since the initiation of biofeedback therapy. no complaints of soreness were made during biofeedback training. At the end of wrist extension training. she started clapping with her left hand to music. The schedule was similar to the one implemented for finger extension training (two sessions a week). that influence the choice of modality. This same observation was also made by staff in the client's speech therapy class. however. After 10 ses­ sions. goniometric measurements indicated 84 degrees of wrist flexion and 66 degrees of wrist ulnar deviation.

1977 11. et al: Developing strategies for biofeedback: Applications in neurologically handicapped patients. et al: Sensory feedback therapy of spasmodic torticollis and dystonia: Results in treatment of 55 patients. Wolf SL. 1978 3. AJOT 8:95-99. Phys Ther 57:402-408. Wolf SL: Procedures for EMG biofeedback training in involved upper extremities of hemiplegic patients. Am J Ment Defic 71:279-282. Brudny J. 1966 12. 1973 4. October 1981 1451 . wrist extension. Basmajian JV. Regenos E. Harrison W. San Francisco. The effectiveness of biofeedback therapy also seemed to be related to the observation that the client was in a setting where she had control of the contingencies: music could be turned on by the client whenever a finger and wrist extensor response (EMG activity) exceeded the preset threshold level. 1974 7. Arch Phys Med Rehabil 56:231-236. Brudny J. et al: Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: Effects on voluntary control and strength. Ayres AJ: Ontogenetic principles in the development of arm and hand functions. Grynbaum BB. 1975. Basmajian JV: Biofeedback in physical medicine and rehabilitation. Baker MP. 1976 8. Korein J. Nafpliotis H: Electromyographic feedback to improve ankle dorsiflexion. REFERENCES 1. biofeedback therapy provides a setting in which the contingencies are determined by the individual. Kleinman KM: Use of electromyographic feedback to increase inhibitory control of spastic muscles. The rapid devel­ opment of extension movements and the observations that improved motor function appeared outside the therapy setting indicate the possibilities of EMG bio­ feedback in neuromuscular reeducation for mentally retarded individuals. Arch Phys Med Rehabil 55:403-408. et al: The effect of music and exercise upon the self-help skills of nonverbal retardates. Severely and profoundly retarded individuals typically en­ counter situations where others take care of their needs and thus develop a history best described as "learned helplessness. Freeman & Co. In our study. Am J Ment Defic 82:7983. Baker M. Amato A. and hand grasp. Phys Ther 59:1500-1507.11 These findings in­ dicate that feedback presentation in the auditory mode may be an initial point of investigation in training the mentally retarded population to process information. auditory feedback (FM music) was effective in facilitating the appropriate motor re­ sponses. Phys Ther 56: 821-825. Publishers."12 In contrast. 1977 2. pp 181-188 Volume 61 / Number 10. Narayan MG. Temerlin MK. 1979 9.profoundly retarded individuals. Korein J: Spasmodic torticollis: Treatment by feedback display of the EMG. Development. 1976 6. CA. Seligman MEP: Helplessness: On Depression. W. 1954 10. Grynbaum BB. H. Fernando CK. 1975 5. and Death. Adv Neurol 14:375-402. Krupski A: Role of attention in the reaction-time performance of mentally retarded adolescents. Hermsmeyer CA. Kelly JL. Biofeedback Self Regul 3:435-455. Lecrone H. Kukulka CG. Phys Ther 53:1063-1066.

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