biofeedback EMG system for physiotherapy rehabilitation

the future of physiotherapy now

user manual
2 | | physioplux user manual
 [version 2.2.4 9th September 2016]

ATTENTION: please read this manual

before using your physioplux product

The information contained in this manual has been carefully checked and
were made every effort to ensure its quality. PLUX reserves the right to make
changes and improvements to this manual and products referenced at any time
without notice.

The word Bluetooth and its logo are trademarks of Bluetooth SIG Inc. and any
use of such marks is under license. Other trademarks are the property of their
respective owners.

©2016 PLUX, Wireless Biosignals S.A.

physioplux user manual | Introduction | 3
PLUX Wireless Biosignals, S.A.
email: plux@plux.info
web: http://www.plux.info
Headquarters
Zona Industrial das Corredouras, Lt. 14 - 1º
2630-369 Arruda dos Vinhos
Portugal
tel.: +351 263 978 572
fax: +351 263 240 902
Lisbon Office
Av. 5 de Outubro, nº 70, 8º
1050-059 Lisboa
Portugal
tel.: +351 211 956 542
fax: +351 211 956 546

4 | Introduction | physioplux user manual

 Contents
Chapter 1: Your physioplux. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Contents of the packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chapter 2: Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Getting started with your physioplux device . . . . . . . . . . . . . . . . . . 9
Know the device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Switching it on. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Connecting the sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Disconnecting the sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Recharging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Accessories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Set of sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
How to use the electromyography sensors (sEMG) . . . . . . . . . . . . . . 13
Recommendations for proper monitoring of electromyography signal . . . . . . . . 13
Chapter 3: Software. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
If you are using the software for the first time . . . . . . . . . . . . . . . . 14
Start menu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
System messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Bars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Chapter 4: Information about safety, support and quality . . . . . . . . . . . . 25
Intended Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Classification and identification . . . . . . . . . . . . . . . . . . . . . . . . 25
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Warnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Electromagnetic emissions . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Maintenance recommendations . . . . . . . . . . . . . . . . . . . . . . . . 29
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Transport and storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Technical specifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
bioPLUX device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Charger | FW7600/09 charger with universal battery. . . . . . . . . . . . . . . . . . 30
Technical assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
FAQs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Guarantee of quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Clinical Guides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
physioplux user manual | Introduction | 5
6 | Introduction | physioplux user manual
 Chapter 1: Your physioplux
Physioplux makes the acquisition of the muscular signals received in the
user’s body by the electromyographic sensors, and transmits them in real time
via Bluetooth to the tablet. There, they are processed and displayed in real
time, during the training exercises. Awareness and perception of the muscular
activation and the body movement is facilitated and the goals easily achieved.

At the end of each training session is automatically generated a report that is

added to the user profile in the database system.

Biofeedback is generally defined as a method of psychophysiological training

through electronic equipment and consists of the capture of signals produced by
the human body and its presentation in real time to the user. Electromyographic
Biofeedback is a tool used to aid the training of physical rehabilitation in
physiotherapy.

The purpose of training with biofeedback is self-regulation. The user learns

how to control both the physical and mental processes to operate better and
healthier his body, enhancing the rehabilitation and improvement of physical
performance.

On electromyographic biofeedback, electrical signals resulting from muscle

activity are translated by the biofeedback software in graphics and animation
appealing to the user, guiding him in his workout muscle rehabilitation.

The physioplux has a major philosophy of ease of use, flexibility, reliability

and portability.

The operating principle of the physioplux is based on three principles: to

connect, acquire and visualize. The objective of this system is to facilitate the
work of the physiotherapist and, through nice graphics, enhance the perception
of movement by the user.

The physioplux begins collecting biosignals by the sensors placed on the

skin of the user that are connected to the signal acquisition bioPLUX device.
This device gets the signals and sends them (in real time) via Bluetooth to the
tablet. These signals are processed and transformed into attractive graphics
and animations that are viewed by the user and therapist on the tablet screen
through the software.
physioplux user manual | Chapter 1 | 7
 The software offers all the functionality that is intended to be implement
by the physioplux product: visualization in real-time of the running training
session, view reports from previous sessions, printing of reports, setting goals
to be achieved by the user in each session of training and checking of historical
charts of sessions.

Contents of the packaging

The package contains:
• 1 wireless wearable clip
• 1 portable tablet w/ physioplux software installed
• 4 EMG sensors + 1 ground cable
• 24 electrodes
• 1 table stand for tablet
• 2 chargers (tablet and bioPLUX)

PHYSIOPLUX PRO PHYSIOPLUX SOLO PHYSIOPLUX EXPERT

• 1 bioPLUX wireless
system with 8 channels
for electromyographic
biofeedback
• All existing biofeedback
applications pre-installed.
• 4 sensors for surface
electromyography
• 1 bioPLUX wireless • 1 bioPLUX wireless
system with 4 channels system with 8 channels
for electromyographic for electromyographic
biofeedback biofeedback
• 1 set of biofeedback • All existing biofeedback
applications (specific zone or applications pre-installed
generic)
• 4 sensors for surface • CD with research software
electromyography OR
2 sensors for surface
electromyography + pelvic
floor probe

NOTE: Extra sensors can be purchased from PLUX.

8 | Chapter 1 | physioplux user manual

 Chapter 2: Hardware
Getting started with your physioplux device
Know the device
The bioPLUX is the device that collects and digitizes the signals from the sensors
and transmits via Bluetooth to the tablet, where they are viewed in real time.

The channels of bioPLUX have 12 bits, and its sampling frequency is 1000Hz.

The bioPLUX also has a terminal for connecting the AC adapter and charge
the internal battery (which allows an autonomy of 12 hours), and a channel to
connect the reference electrode (ground cable), which is essential for the proper
monitoring of electromyography signal.

status indicator
of the bioPLUX system

analogic channels
1 to 4 with
36 to 1000Hz sampling
ON / OFF
button
channel to
connect reference
electrode

connector to
recharge battery

physioplux user manual | Chapter 2 | 9

 Switching it on
In order for the device to work, it must be switched on:

to switch it on,
move the button to
the ON positon

after switching ON, the led status light blinks once per second and the device is
in “switched ON” mode

Connecting the sensors

The sensors should be connected to channels 1 through 4, as shown in the
figure below. The reference electrode/ground cable should be connected to the
respective channel (see identification of channels on page 9).

When connecting the sensors, pay attention to where the cables go to avoid
disrupting the patient’s movements.

connect the sensor to the physioplux channel

Disconnecting the sensors

To avoid damaging the bioPLUX device or the sensors, they should be
disconnected in line with the recommendations shown below:
• don’t twist the sensor while disconnecting
• don’t apply upward force or pull the cable
• use minimal force to disconnect

10 | Chapter 2 | physioplux user manual

 Recharging
The bioPLUX has an autonomy of approximately 12 hours in continuous usage.
When the battery starts to run down, the respective led light gives a warning
until the device stops working. At this point you need to recharge the battery.

To charge the battery of your bioPLUX device all you have to do is plug the
charger to a wall outlet and to the charging terminal on your bioPLUX device.

The bioPLUX battery will take approximately two and a half hours to fully
charge. When this process is finished and the
battery is fully charged the led charge warning
light switches off. You can use the bioPLUX while
charging.

In an error occurs during charging, a red led

warning light comes on. In this case, you must
unplug the charger from the wall outlet and plug it again to complete the
charging process correctly.

The room temperature when charging the battery must be between 10ºC and 35ºC.

If the battery overheats (reaching 60ºC), unplug the charger immediately and
contact PLUX Technical Assistance.

physioplux user manual | Chapter 2 | 11

 Accessories
Set of sensors
emgPLUX | surface electromyography sensor
Our miniaturized sEMG active sensors have
low noise characteristics that allows them
to be used in the most adverse condition of
EMG acquistion.
The amplification and signal conditioning
elements placed near the acquisition area
maximizes the sensors performance and final
signal quality.
Some of the applications of this sensor
include fatigue evaluation, muscle contration
monitoring and muscular activation instants
analysis.

respPLUX | respiration sensor

Our compact respiration sensor integrates an
airPLUX air pressure sensor to measure the
pressure differences within a sealed chamber.
With high sensitivity it is specially designed
to measure abdominal or thoracic respiratory
cycles.
Some of the applications of this sensor include
thoracic cavity displacement measurement
and respiratory cycles observation.

pelviPLUX | vaginal probe

Pelvic floor muscles rehabilitation main
focus is related with urinary incontinence.
Biofeedback techniques enable the patient
to improve pelvic muscles function, through
muscle awareness, which leads to increase
muscle strenght and coordination.

12 | Chapter 2 | physioplux user manual

 How to use the electromyography sensors (sEMG)
The emgPLUX sensors are designed to capture electromyography (sEMG) signals
from the skin surface . After the correct placement of the sensor on the muscle that
you want to monitor, the signals are captured and transmitted by the bioPLUX device
to the tablet, where the biofeedback software process them and translate them into
graphics and animations that are displayed, real time on-screen.
It is advised that the application of the electrodes on the skin should be with a
distance of 2 cm between each center, with a parallel orientation to the muscle fibers.
For the monitoring of the muscle activity it is necessary to use at all times, a
reference electrode with the ground cable. This electrode collects the basic electrical
signal always present at skin surface and that is not a result of muscle activity (noise).
This signal is the reference to measure the signal and the ground cable must be
placed on a location with reduced muscle activity. Thus, the electromyography signal
captured and processed represents only the signal generated by the activity of the
muscle where the bipolar sensor was placed.

Recommendations for proper monitoring of electromyography signal

1. The skin where the sensors are placed (including the reference) must be prepared by removing
the existing hair on the surface;
2. Clean the skin with alcohol and let it evaporate before placing the electrodes;
3. Place a detection surface on each electrode;
4. For a good contact of the the electrodes with the skin, you should press firmly the center and
the edges of the detection surfaces;
5. The reference electrode should be placed in a place on the body with low electrical activity,
like for ex. on the elbow or ankle;
6. Wait about 30 seconds;
7. Connect the sensors to the electromyography acquisition system bioPLUX, to the desired
channels (Channel 1 to Channel 4);
8. Connect the reference electrode to the appropriate channel in bioPLUX (channel G);
9. Test, using the software, if the signals recorded by the electromyography sensors are received.

Placing the emgPLUX sensor Reference electrode

Important: The pads must not be applied to broken skin or on the nipples, bony
protrusions, cuts, lesions or scars. Their use must be personal and should be
discarded after use.

physioplux user manual | Chapter 2 | 13

 Chapter 3: Software
If you are using the software for the first time
The first time you use the physioplux software, please go to “settings” and
check if you have a unique identification code (MAC address) for the bioPLUX
system that you are about to use and confirm, that this is the same as the one
on the hub.

Start menu
The initial menu is shown when the software starts and contains four options:
• patients - access to the users’ database
(choose applications, assessments and view reports)
• monitor - raw signals visualization
• bars - signals visualization and training in the form of a graphic bar
• settings - configuration of the mac address

14 | Chapter 3 | physioplux user manual

 System messages
The software sends messages that informs about the bioPLUX device
connection state. Messages are recorded by the software so that, in situations of
failure, PLUX technicians can easily identify the type of occurrence.

The warning appears as with a warning image and after clicking the error
message can be:
• OK
• This application is not compatible with this version of the device bioPLUX
• Specified address is not correct. Verify that consists of six (6) alphanumeric
characters separated by a colon (:) [xx: xx: xx: xx: xx: xx]
• The Bluetooth adapter was not found. Verify that an adapter is connected
and turned on
• The device bioPlux was not found. Verify that you are within range, and that
the battery is ok (red light off)
• The computer has lost contact with the device bioPlux. Verify that you are
within range, on, and that the battery is ok (red light off)
• The communication port does not exist or is already in use
• The communication port can not be initialized. The supplied parameter
cannot be changed
• The communication port is already open
• The device’s firmware version is not supported
• The communication port is not open
• The bioPLUX device is not available
• The bioPLUX device is already in acquisition mode
• The bioPLUX device is not in acquisition mode
• The communication port can not be closed
• The bioPLUX device is not paired
• Invalid parameter
• Invalid function
• Unknown error

physioplux user manual | Chapter 3 | 15

 Bars
The “bars” button accesses a screen showing a display of electromyographic
signals in the form of animated bars. This option is recommended to save
time, allowing to perform a fast calibration and so, to start the training session
immediately. .

You can monitor up to four electromyography signals using the four channels
of bioPLUX. Each bar corresponds to a channel of the device, being possible
to establish a threshold of muscle contraction for each channel. When the
thresholds are met in all channels simultaneously, it is considered that the
purpose of training is being met: all bars are green and the counter on the left
of the screen registers the time (in seconds) during which the target is met. Once
the threshold is not met, the bar turns red and the counter goes back to zero
seconds. The counter restarts only when the target is back on track. On the right
of the screen, you have a counter to record the best result achieved.

Monitor
The “monitor”, displays the electromyographic signal in the form of a line
graph that represents the surrounding RMS. It is available in 1 and 4 channels
for filtered EMG signal, and 8 channels for raw signal.

16 | Chapter 3 | physioplux user manual

 On this screen, the user / therapist can make a preliminary assessment of the
placement of sensors and performance of the user. It can be important since it allows
to collect information useful in the definition of a rehabilitation program specific to the
user. The special and unique specifications set by the therapist for each user can then
be applied in a unique and custom section by entering the “patients” in the main menu.

Patients
To access menu patients, the user must be registered at Fiware (https://account.
lab.fiware.org/sign_up/). These same credentials will allow to access data from
home sessions executed with Physioplux TRAINER at https://cloud.physioplux.com/.
The “patients” option in the main menu allows to:
• make the management of the users in the database
• conduct specialized training sessions for each user
• see the progression of users over time
• view and print reports of the training sessions

physioplux user manual | Chapter 3 | 17

 Add a patient
By clicking the “add” button, a form appears to be completed with information
about the patient.

18 | Chapter 3 | physioplux user manual

 Besides the patient’s basic profile information, you can edit data about the
occurrences. An occurrence is an event or incident that caused a particular injury.

Each time a user starts a therapy for an injury or problem it is advisable to

create a new occurrence, to facilitate the introduction of any medical information
relevant to the new rehabilitation program. Training sessions conducted in the
context of this occurrence will therefore be separated from those carried out in
other contexts.

Warning: if you delete an occurrence, all reports associated with it will be deleted.

Patient Screen
In the patient’s screen, you can start new applications, see reports and edit the
patient’s profile.

Before starting any applications, please select the occurrence from the list
above the 3 buttons.

physioplux user manual | Chapter 3 | 19

 Homework prescription
To prescribe homework to a patient, 2 EMG wireless sensors, named muscleBANs
BE, are needed to monitor the homework at their home. It is advisable that the
physioplux TRAINER app is installed on the patient’s own Android smartphone
while at the clinic so that its usage can be explained. If the patient does not
possess an Android phone, or has an old one, it should be possible for the clinic
to sell/borrow one.

Physioplux app works as usual, but a new button to assign homework is

available, which will open a new screen with exercise settings. By default, the
exercises available will be the ones on the same phase as the new assessment
screen that comes up before training, to validate in which motor relearning
phase the patient is in.

prescribe homework

20 | Chapter 3 | physioplux user manual

 Variance
Is a setting to control the auto-adjust limits, in relation to the targets defined
by the physiotherapist. Auto-adjust is a feature available to patients while per-
forming the homework, which allows to recalibrate the two monitored muscles,
sometimes needed because electrical muscle activity can vary from time to time
and the exercise might be very hard to execute and targets (green bars) impos-
sible to achieve.

Frequency
Series Number of exercise series the patient should perform per home session (ex: 3
series of active scapular depression)
Rest between series How many seconds the patient should rest between each serie
(ex: 5 seconds)
Repetitions per workout Number of exercise repetitions the patient should perform per
serie (ex. 10 repetitions of active scapular depression, times 3 series)
Rest between repetitions How many seconds the patient should rest between each
exercises repetition (ex: 2 seconds)
Repetitions duration How many seconds the patient should hold the contraction per
repetition (ex: each active scapular depression must long 10 seconds)
Times per week Number of days in a week, the patient should execute this homework.

physioplux user manual | Chapter 3 | 21

 Reports
The screen “report” contains a list of applications already made for a particular
occurrence. Clicking on the icon of a application accesses the patient’s progression
chart for this application. Each point on the graph corresponds to a different session.

To view the report of the session you want, simply click on the button with the
session time and date. You can then, if desired, edit the comments section of the
report and print it.

The patient progression is indicated for every assessment performed and pain
assessment (when done).

delete report print report to PDF

22 | Chapter 3 | physioplux user manual

 The report contains the following information:
• patient’s personal data
• identification of the application
• parameters of the exercises conducted during the session
(objectives, level of tolerance ...)
• results
• comments (editable)
• name of the technician in charge (editable).

Applications
Clicking on the icon “applications” gives you the list of training applications
that can be executed.

A rehabilitation training application consists of a sequence of steps that the

patient performs to reach a certain goal. Usually, the first steps of an application
are calibration steps and / or preparation for the exercise (or exercises), which
aims to re-educate the muscles. The exercises should be conducted under the
guidance of a physiotherapist.

There are generic training applications and specific applications for specific
therapeutic situations. In the generic applications, the therapist has the ability
to set parameters manually and adjust the application to the muscles desired,
unlike the specific applications that are designed for particular therapies, more
automated and directed to pre-determined muscles (or muscle groups).

The software includes, by default, 10 concluded applications, devided into area

folders as knee, shoulder, pelvic and generic. The applications are:
• dynamic stability - patellofemoral
• ACL
• dynamic stability - shoulder
• pelvic floor man
• pelvic floor woman
• Rapid Contractions
• dynamic stability - generic
• biofeedback - generic
• postoperative recovery
• generic balance

Is also available a folder with beta applications.

physioplux user manual | Chapter 3 | 23

 Session
All screens throughout the application have a header that identifies the
application that is taking place, the patient and the current step of the protocol.

In addition to the identifying icons of the application, there is also the icon
“home”. By clicking on this icon, the application is canceled and returns to the
start menu. Clicking on the icon of the user, the application is canceled and
returns to the menu of the patient. Clicking on the icon of the identification
application, this is canceled and returns to the menu of applications.

Once completed, seemingly every step of an application, click the “confirm” to

proceed to next step. If you wish to cancel a step and go to a previous step, click
“cancel” and return to previous screen.

NOTE: For reference about each application, you can visit the product’s official
website http://www.physioplux.com.

24 | Chapter 3 | physioplux user manual

 Chapter 4:
Information about safety, support and quality
Intended Use
The physioplux software is an electromyographic (EMG) biofeedback system
designed for physiotherapists that provides real-time muscular feedback. It is
intended for analysis of patient muscular activity generated by a medical device
(bioPLUX) with a view to treat and monitor. It is a component and integral part
of a medical device.

Classification and identification

In accordance with the Decree-Law Nº 273/95 of 23 October.

Device Class I with measuring function, Annex VII.

Internally powered equipment (IEC 60601-1). Class II device when connected

to external power supply (IEC 60601-1).

Device with applicable parts of the type BF (IEC 60601-1).

Non-ionizing electromagnetic radiation. The device includes radio frequencies

transmissions likely to cause interference with other equipment.

Serial number (affixed to the physioplux device).

Contraindications
Do not use this device in patients with implanted electronic devices of any
kind, including pace-makers, electronic infusion pumps, stimulators, defibrillators
or similar.

Do not apply electrodes over damaged skin.

Do not use the system in patients with allergies to silver.

physioplux user manual | Chapter 4 | 25

 Warnings
! See all the documentation that came with the system for instructions on safety and
precaution.
! See the User’s Guide for detailed
comments instructions about bioPLUX and sensors.
! Always keep the device and its accessories dry. The presence of liquid contact can
compromise the safety operating characteristics of the system.
technician’s name
! Fragile. Handle with caution. Do not expose the device or accessories to high
accelerations and vibrations.
! In compliance with the European Directive on Waste of Electrical and Electronic
Equipment (WEEE) 2002/96/EC, do not deposit the bioPLUX in the trash. Instead,
contact your Reseller or PLUX for properly recycle your bioPLUX. You can get
information about the contact nearest to you in http://www.plux.info.
! The bioPLUX device should be used at temperatures between 10º and 40ºC and
stored at temperatures between 10º and 30ºC because it has rechargeable Li-
Ion batteries and detection surfaces with limitations on operating temperatures.
Operating or storing the device outside this range may compromise the integrity
and security of it.
! Do not use this equipment in an environment with operating magnetic resonance
imaging devices (MRI).
! Do not use the device near the fire or in potentially explosive atmospheres, such as
atmospheres with flammable gas.
! The use of damaged accessories or not recommended by PLUX may result in
changes to the technical characteristics and features of your bioPLUX. Use only
approved accessories purchased from PLUX or an PLUX agent.
! Use only the detection surfaces provided on the packaging of the system or acquired
from PLUX or an PLUX agent.
! The detection surfaces provided are single-user and disposable.
! Use only the transformer supplied with the package of the system or purchased
from PLUX or an PLUX agent.
! Inspect the sensors on a regular basis to ensure that they remain in good working
order.
! If you experience any kind of discomfort or skin irritation when using the clinical
bioPLUX, discontinue using it immediately.
! The bioPLUX should not be used continuously for periods of time above 60 minutes.
! Do not place the device in the microwave.
! If the bioPLUX system or accessories reach uncomfortable temperatures, turn off the
bioPLUX immediately and contact Technical Support.
! Do not insert objects into the holes of the device, it may affect the operating
characteristics, and safety.

26 | Chapter 4 | physioplux user manual

! Do not open the bioPLUX or its accessories. The repair of the same should be only
done by properly authorized PLUX personnel.
! By connecting the bioPLUX to the transformer for batteries recharge, place the
device so that the cable is free, away from places where it can be walked on or
damaged. Make sure the cable does not obstruct the passage of people.
! Use the sensor cables with extreme caution to avoid risk of strangulation.
! The bioPLUX may suffer or cause interference to other equipment with radio receiver
/ transmitters, even those that comply with international standards. Keep a safe
distance between the bioPLUX and other devices to ensure their proper functioning.
! This equipment complies with International Standard EN 60601-1-2:2001 for
electromagnetic compatibility for medical equipment and systems. This pattern
is used to provide reasonable protection against harmful interference in a typical
medical environment. However, the proliferation of devices using radio frequencies
can cause interference that can reach the limit to prevent the proper functioning
of your bioPLUX. Keep your medical equipment installed in accordance with their
instructions.
! If your bioPLUX stops working properly, do not use it until you send it for repair by
qualified PLUX personnel.
! Use bioPLUX within the limits of communication with the receiving equipment
of the wireless signal: in a radius of approximately 10 meters for the Bluetooth
connection. Working with the device outside of this range of communication can
lead to data loss and faulty communications.
! Exposure to radio-frequency.
! The physioplux radiation emission levels are in accordance with the limits
of exposure to radiation allowed by the FCC ( transmission module with FCC
ID:QoQwT12). Nevertheless, the device must be used in a way to minimize human
contact during normal operation. Use the bioPLUX clinical only for the necessary
period of time.
! The bioPLUX should not be used in noisy environments in relation to RF radiation
wich can cause communication failures with the computer.
! Do not immerse the sensors or the bioPLUX, nor clean with liquid or with abrasives.
Read the manual to learn how to clean up the bioPLUX and sensors.

physioplux user manual | Chapter 4 | 27

 Electromagnetic emissions
See the table below for specific information regarding the bioPLUX electro-
magnetic emissions.

The bioPLUX is intended for use in the electromagnetic environment specified

below. The client and / or user of this device should ensure that it is used in such
an environment.
The bioPLUX is intended for use in the electromagnetic environment specified below. The client
and / or user of this device should ensure that it is used in such an environment.
Electromagnetic
Emissions test Compliance
Environment - Guidance
This device must emit
electromagnetic energy in
RF Emissions
Group 1 order to perform its function.
CISPR 11
Electronic equipment near it,
may be affected.
RF Emissions This device is suitable for
Class B
CISPR 11 use in all establishments,
including domestic and
Harmonic Emissions
A those directly connected to
IEC 61000-3-2
low-voltage energy public
Voltage fluctuations / network supply which supplies
Flicker Emission Conforms buildings used for domestic
IEC 61000-3-3 purposes.
Table 1: Electromagnetic Emissions

This device is suitable for use in all establishments, including domestic and
those directly connected to low-voltage energy public network supply which
supplies buildings used for domestic purposes.

28 | Chapter 4 | physioplux user manual

 Maintenance recommendations
Cleaning
• the bioPLUX equipment and sensors should be visually checked before
each use to ensure that no mechanical damage has occurred.
• the bioPLUX equipment and sensors (including the cables) should be
cleaned with a slightly damp cloth or suitable absorbent paper, ensuring
that no liquid enters the equipment or sensors. Do not use detergent or
any type of cleaning liquid.
• Clean the bioPLUX equipment separately from the sensors
• Do not clean or re-use detection surfaces. They are only suitable for single
use, and should be disposed of after usage.

Transport and storage

• When the equipment and accessories are not being used, they should be
stored in the original box in a dry place:
– Relative humidity: up to 95% with no condensation
– Ambient temperature: 10ºC to 30ºC
– Atmospheric pressure between 500 hPa and 1060hPa
• Whenever the equipment needs to be transported, it should be placed
in the original box, since this was designed and tested to ensure the
equipment and accessories are securely stored;
• Take care while handling the bag and avoid dropping it, since the device
is not shock-proof and should not be placed under stress or sudden
acceleration.

PLUX can not be held responsible if the system is transported outside it’s
original box or in any other type of unsuitable packaging, which may invalidate
the guarantee.

physioplux user manual | Chapter 4 | 29

 Technical specifications
bioPLUX device
Description
Wireless Connectivity via bluetooth with range of 10m. Class 2 Bluetooth
4 analogical channels at 12 bit with 1000Hz sampling
Weight 46g
Dimensions 82 mm x 54 mm x 15 mm

Charger | FW7600/09 charger with universal battery

Description
Input 100 to 240 V~, 50 to 60 Hz, 0.5A
Output 5V, 1.2A
Conforms with IEC 60950

30 | Chapter 4 | physioplux user manual

 Technical assistance
PLUX provides Technical Assistance for all the equipment it supplies, and
damaged parts, accessories or bioPLUX devices may be substituted or repaired.

Technical Assistance is provided at PLUX’s premises.

Even if the system is under guarantee, before calling a Technician please carry
out a few simple checks to see if the problem can be solved without requesting
support. See if following questions help in resolving the matter. If you are unable
to solve the problem, contact PLUX technical support:

email: suporte@plux.info
telephone: +351 211 956 542

FAQs
1. I started the biofeedback software, connected the bioPLUX device and the
sensors, but no signal appears on the monitor.
Before taking any action, make sure that any error messages appeared at the
bottom of the screen and, if so, what is the message. Some messages are self-ex-
planatory and can help you resolve your problem. If you can not solve the prob-
lem, disconnect the device, restart the software and reconnect the device.

2. The bioPLUX is switched on but it does not work. What should I do?
Check to see whether the battery is low or needs charging. Autonomy is ap-
proximately 12 hours. If the battery is low, recharge it (see page 12). If, after re-
charging without problems, the device still does not work, please contact PLUX
technical assistance.

Note: the bioPLUX cannot be used while recharging.

3. The bioPLUX is recharging and, after a time, a red light turned on (in status).
What does it mean?
A stable warning light means that an error occurred during recharging the
bioPLUX device . Disconnect the bioPLUX from the transformer and connect it
again, to finish the recharging process, as described on page 12.

physioplux user manual | Chapter 4 | 31

4. How to check the progress and the previous reports of a particular patient?
Initially, select the user from the list of patients, then select the “Reports” button.
If the user has performed more than a application, select the application that
you want to view in the user’s progress, and there will be a graphic illustration of
progress between sessions. You can then select a specific point on the graphic,
which means a report. See more at page 25.

Guarantee of quality
The physioplux – biofeedback system for physical rehabilitation has a two
year quality guarantee from the date of purchase.

PLUX guarantees that the hardware, accessories and PLUX software will be
free from material or manufacturing defects for two years following date of pur-
chase. If PLUX receives notification of any such defects within the guarantee
period, it will repair or substitute with the same unit\model, any products with
proven defects at no cost to the client. During the repair period PLUX promises
to provide a temporary replacement under the same specification. Repairs will be
carried out at PLUX’s premises after the equipment has been received.

Usage of the device that is not in accordance with the handling instructions
indicated in the manual, or use with accessories other than those manufactured
by PLUX will invalidate this guarantee.

32 | Chapter 4 | physioplux user manual

Safety
The user should read through all the documen-
tation that came with the system for instruc-
tions on safety and precaution.
The user should always keep the device and its
accessories dry.
The user must turn off the physioplux device
and contact Technical Support if the system or
accessories reach uncomfortable temperatures.
The user should not use the physioplux device
in noisy environments (environments with mi-
crowaves and other similar equipment).
The user should not use the physioplux device
in an environment with operating magnetic
resonance imaging devices (MRI).
The user must not use the device near the fire
or in potentially explosive atmospheres, such
as atmospheres with flammable gas.
The user should only use the detection surfaces
or other approved accessories purchased from
PLUX or by a PLUX agent.
The user should only use the transformer sup-
plied with the package of the system or pur-
chased from PLUX or by a PLUX agent.
The user should inspect the sensors on a reg-
ular basis to ensure that they remain in good
working order.
The user should stop using the physioplux de-
vice if experience any kind of discomfort or skin
irritation.
The user should not use the physioplux device
continuously for periods of time above 60 min-
utes.
Do not use the system in patients with allergies
to silver.
The user should dispose detection surfaces af-
ter using the physioplux device. Detection sur-
faces are single-user and disposable.
The user must not place the device in the mi-
crowave.
The user must not insert objects into the holes
of the device.
The user should not open the physioplux de-
vice or its accessories. The repair of the same
should be only done by properly authorized
PLUX personnel.
The user should make sure the cable does not
obstruct the passage of people.
The user should use the sensor cables with
extreme caution to avoid risk of strangulation.
The user should keep a safe distance between
the physioplux device and other devices to en-
sure their proper functioning.
The user should only send the device to repair
to qualified PLUX personnel.
The user should not immerse the sensors or
the physioplux device, nor clean with liquid or
abrasives.
The user should handle the physioplux device
with caution and not expose the device or ac-
cessories to high accelerations and vibrations.
The physioplux device should not be used in
patients with implanted electronic devices of
any kind, including pace-makers, electronic
infusion pumps, stimulators, defibrillators or
similar.
Do not apply electrodes over damaged skin.
The physioplux device should contain Serial
Number information
physioplux user manual | Safety | 33
34 | physioplux user manual
Clinical Guides

physioplux user manual | Clinical Guides | 35

CLINICAL GUIDANCE
TABLE OF CONTENTS
SHOULDER CONDITIONS
PATELLOFEMORAL PAIN SYNDROME
ACL POST-OP RECOVERY
CONTRAINDICATIONS
WHY USE PHYSIOPLUX
IN THE MOTOR
RELEARNING PROCESS?
FOR MOST CASES
PREVENT INCIDENT RECURRENCE
IMPROVE OUTCOMES, LESSEN NUMBER
OF SESSIONS REQUIRED AND REDUCE
INCIDENT RECURRENCE
REAL TIME VISUAL FEEDBACK,
WITH APPEALING GRAPHICS
THAT REPRESENT MUSCLES ACTIVITY
TO MORE EFFECTIVELY LEARN THE RIGHT PATTERN
AND AVOID MUSCLE ADAPTATIONS
OBJECTIVELY TRACK
THE MOTOR CONTROL RELEARNING PROGRESS
USING ACTIVATION TIMINGS & COMPARE
AGAINST ASYMPTOMATIC SIDE

MOTOR
RELEARNING MODEL
FITTS & POSNER 1
COGNITIVE STAGE
AWARENESS EXERCISES SHOULD BE MAINTAINED
FOR 10SECS 2 FOR EACH LOCAL STABILIZER MUSCLE,
WITHOUT COMPENSATIONS, IN DIFFERENT
POSITIONS (SUPINE, PRONE, SITTING, STANDING)
RECOGNIZE NEUTRAL ZONE AND MAINTAIN
LOCAL STABILIZERS CONTRACTION
EXERCISES SHOULD BE SIMPLE
THIS STAGE REQUIRES HIGH ATTENTION LEVELS
AND COGNITIVE DEMAND WITH VARIABILITY OF
THE INITIAL PERFORMANCE
THERE IS A TENDENCY TO OPTIMIZE THE TASK,
DUE TO THE REPETITION OF THE ACTION
SHOULD BE GIVEN A HIGH FEEDBACK LEVEL AND
HIGH FREQUENCY OF TREATMENT SESSIONS
1 Fitts & Posner, cit. by Wulf, 2007
2 Santos e Matias, 2007
ASSOCIATIVE STAGE
MAINTAINED ACTIVATION OF THE LOCAL
STABILIZERS FOR 2X 30SECS 2 IN THE NEUTRAL ZONE
MAINTAINED SAME ACTIVATION LEVELS
IN DIFFERENT POSITIONS AND PLANES
OF MOVEMENT AND WITH REDUCED FEEDBACK
MAINTAINED ACTIVATION DISSOCIATED
OF NORMAL BREATHING
MAINTAINED ACTIVATION WITHOUT
BIG EFFORT REQUIRED
LOWER PERFORMANCE VARIABILITY
LONGEST PHASE OF MOTOR LEARNING
SHOULDER
IMPINGEMENT & GU INSTABILITY
AUTONOMOUS STAGE
MAINTAINED ACTIVATION IN DIFFERENT
DAILY LIFE ACTIVITIES, WITH REDUCED FEEDBACK
AND PROGRESSIVELY WITHOUT FEEDBACK
GREATER FOCUS ON FUNCTIONAL TASKS
REDUCED LEVELS OF ATTENTION
AND EFFORT REQUIRED
GOAL IS TO ACHIEVE AUTOMATISM
AND EASE IN PERFORMING TASKS
LOWER FREQUENCY OF TREATMENT SESSIONS
SHOULDER
TREATMENT
PLAN SAMPLES
PER CONDITION
IMPINGEMENT 1 POST-OP 2

COGNITIVE ASSOCIATIVE AUTONOMOUS COGNITIVE ASSOCIATIVE AUTONOMOUS

1-2 4-8 2-4 WEEKS 2-4 4-12 2-6

1-3 4-12 2-6 SESSIONS 4-8 4-16 2-6

APPLICATIONS: EVALUATION, GENERIC, DYNAMIC STABILITY SHOULDER APPLICATIONS: POST-OP, EVALUATION, GENERIC, DYNAMIC STABILITY SHOULDER

EVALUATION DYNAMIC STABILITY DYNAMIC STABILITY

APPLICATION
SHOULDER APPLICATION GENERIC
8 CHANNELS TO EVALUATE AND COMPARE THE
MAIN 4 SUPERFICIAL MUSCLES IN BOTH USEFUL TO COMPARE 2 MUSCLES IN EACH
DESIGNED TO ASSESS ORDERS OF ACTIVATION SHOULDER WITH THE PURPOSE OF TRAINING
SHOULDERS, ACCORDING TO THE DYNAMIC
AND MAXIMUM VOLUNTARY CONTRACTION AND HAVE FEEDBACK
STABILITY PRINCIPLE
BETWEEN 4 IMPORTANT MUSCLES:
(NEW APPLICATION COMING SOON!)
SERRATUS ANTERIOR AND INFERIOR TRAPEZIUS
(LOCAL STABILIZERS) & ANTERIOR DELTOID AND
UPPER TRAPEZIUS (GLOBAL SYSTEM MUSCLES)
1 Santos e Matias, 2007
2 Clinical Reasoning
 SHOULDER
MOTOR IMPINGEMENT

RELEARNING
PROGRESSION
OBJECTIVES
1

IMPINGEMENT
COGNITIVE STAGE ASSOCIATIVE STAGE AUTONOMOUS STAGE
ASSESS AND PROMOTE LOCAL STABILIZER MAINTAINING THE SAME LEVELS OF MAINTAINING CONTRACTION IN DIFFERENT
MUSCLES (INFERIOR TRAPEZIUS & SERRATUS CONTRACTION IN DIFFERENT POSITIONS DAILY ACTIVITIES, WITH GOOD CONTROL
ANTERIOR) ACTIVATION DISSOCIATED FROM (SUPINE, PRONE, SITTING, STANDING) OF THE SCAPULA ACROSS THE MOVEMENT,
GLOBAL SYSTEM MUSCLES (DELTOID ANTERIOR & WITH THE SCAPULA IN THE IDEAL POSITION WITHOUT DECOAPTATION OF THE LOWER ANGLE
UPPER TRAPEZIUS) AND/OR THE INNER EDGE OF THE SCAPULA
AND WITH LOW FEEDBACK (JUST WATCHING THE GOAL IS TO DECREASE FEEDBACK LEVELS
ACTIVATION FIRST WITH FEEDBACK AND WHEN THE GRAPHICS IN CASE OF GREAT NEED)
WELL EXECUTED, WITHOUT FEEDBACK MAINTAINING CONTRACTION IN DIFFERENT
DAILY ACTIVITIES WITHOUT FEEDBACK
RECOVERY OF NEUTRAL ZONE ((RE)PUT SCAPULA
ON AN IDEAL POSITION) AND MAINTAINING
LOCAL STABILIZERS CONTRACTION WITHOUT
OVERLAPPING OF THE GLOBAL SYSTEM

USUALLY PEOPLE HAVE PAIN WHEN THEY HAVE

A WRONG PATTERN OF MOVEMENT

ACTIVATION TIMINGS (PER PLANE)

E.1

MOVEMENT ASSESSMENT
ACT. TIMING MVC

superior trapezius 1 20.0 ms superior trapezius

1 -82.0
-15.0ms
ms 0.45 v

COMMON
ASSESS

2 2
mobilizers
stabilizers

inferior trapezius -10.0 ms inferior trapezius 509.0

30.0 ms 0.15 v

serratus anterior 3 -4.0 ms serratus anterior 3

LATE
450.0
41.0 ms
LOW
0.18 v
PATIENT ISSUES
(representative values)

deltoid anterior 4 0.0 ms deltoid anterior 4 0.0

0.0ms
ms 0.42 v

STABILIZER MUSCLES SHOULD PRE-ACTIVATE USUALLY PATIENTS HAVE AN OVER ACTIVATION OF SUPERIOR TRAPEZIUS AND DELTOID ANTERIOR, WITH LATE
THE MOVEMENT AND/OR LOW ACTIVATION OF THE SHOULDER STABILIZERS, NAMELY INFERIOR TRAPEZIUS AND SERRATUS ANTERIOR
 AT REST

ASSESS E.2
REST ASSESSMENT

TREATMENT
RELAX STIMULATE WITH EXERCISE RELAX

MVC

superior trapezius 1 0.01 v superior trapezius 1 0.05 v 100% <20% 100% >5% 100% >5% 100% <80%
80 80 80 80 <80%

2 2
mobilizers
stabilizers
inferior trapezius 0.03 v inferior trapezius 0.01 v 60 60 60 60

40 40 40 40

serratus anterior 3 0.00 v serratus anterior 3 0.01 v 20 <20% 20 20 20

>5% >5%

4 4
0 0 0 0
33% 5% 2% 72%
deltoid anterior 0.00 v deltoid anterior 0.00 v superior trapezius inferior trapezius serratus anterior deltoid anterior

MUSCLES AT REST CAN HAVE A RESIDUAL OCCASIONALLY PATIENTS HAVE HYPERACTIVITY
ACTIVATION ON THE UPPER TRAPEZIUS, A VERY RECRUITED
MOBILIZER
USUALLY PATIENTS HAVE INFERIOR TRAPEZIUS
AND SERRATUS ANTERIOR WITH VERY LOW LEVELS
OF ELECTRICAL ACTIVITY, WHICH MEANS THEY
ARE NOT VERY ACTIVE AND INDIRECTLY THAT THEY
ARE NOT RESISTANT

MOTOR
RELEARNING
PROGRESSION
EXERCISES
1
(suggestions)

COGNITIVE STAGE ASSOCIATIVE STAGE AUTONOMOUS STAGE

AWARENESS OF THE INFERIOR TRAPEZIUS MUSCLE PERFORM THE PREVIOUSLY DESCRIBED EXERCISES ADD FUNCTIONAL MOVEMENTS
IN SITTING POSITION, ASK THE PATIENT TO PULL FOR 2X30S IN THE NEUTRAL ZONE, IN SUPINE, AND TRAIN THEM IN DIFFERENT POSITIONS
THE SCAPULA TOWARD HIS CONTRA-LATERAL HIP PRONE, SITTING AND STANDING, FOR BOTH
AND PUT THE SCAPULA IN THE NEUTRAL ZONE LOCAL STABILIZER MUSCLES EXAMPLE: IN SITTING POSITION, IN FRONT OF A
TABLE, HOLD AN OBJECT AS A BOTTLE OF WATER,
AWARENESS OF THE SERRATUS ANTERIOR MUSCLE ADD MOVEMENT TO THE TRAINING PLAN, WITH CONTROL OF THE SCAPULA, AND TAKE IT
IN 4 SUPPORT POSITION, WITH KNEES AND STARTING WITH SMALL RANGES ABOVE YOUR HEAD
ELBOW IN FLECTION, IS ASKED TO THE PATIENT TO OF ANALYTICAL MOVEMENTS
EXTEND THE ELBOW IN THE DIFFERENT PLANES OF MOVEMENT CHECK IF THE PATIENT IS ABLE TO PERFORM
MULTIPLE TASKS WITH CONTROL OF THE SCAPULA
SHOULD REPEATEDLY PERFORM THE EXERCISE START PROGRESSIVELY TO ADD RESISTANCE IN DIFFERENT POSITIONS & SPEED OF MOVEMENT
FOR 10S, APPLYING THE SAME STIMULUS FOR NO TO THE MOVEMENT, USING A WEIGHT
LONGER THAN 5 MINUTES. CHANGE POSITIONS
(SUPINE, PRONE, SITTING, STANDING) AND ASK
THE SAME ACTIVATION.
1 Santos e Matias, 2007

MOTOR
RELEARNING MODEL
FITTS & POSNER 1
COGNITIVE STAGE
AWARENESS EXERCISES SHOULD BE PERFORMED
FOR THE STABILIZER (VASTUS MEDIALIS)
AND MANTAINED FOR 10SECS 2
EXERCISES SHOULD BE SIMPLE
THIS STAGE REQUIRES HIGH ATTENTION LEVELS
AND COGNITIVE DEMAND WITH VARIABILITY OF
THE INITIAL PERFORMANCE
THERE IS A TENDENCY TO OPTIMIZE THE TASK,
DUE TO THE REPETITION OF THE ACTION
SHOULD BE GIVEN A HIGH FEEDBACK LEVEL AND
HIGH FREQUENCY OF TREATMENT SESSIONS
1 Fitts & Posner, cit. by Wulf, 2007
2 Santos e Matias, 2007
ASSOCIATIVE STAGE
MANTAINED ACTIVATION OF THE STABILIZER
(VASTUS MEDIALIS) FOR 2X 30SECS 2
MAINTAINED SAME ACTIVATION LEVELS
IN DIFFERENT POSITIONS AND WITH
REDUCED FEEDBACK
MAINTAINED ACTIVATION DISSOCIATED
OF NORMAL BREATHING
MAINTAINED ACTIVATION WITHOUT
BIG EFFORT REQUIRED
LOWER PERFORMANCE VARIABILITY
LONGEST PHASE OF MOTOR LEARNING
KNEE
PATELLOFEMORAL PAIN SYNDROME
AUTONOMOUS STAGE
MAINTAINED ACTIVATION IN DIFFERENT
DAILY LIFE ACTIVITIES, WITH REDUCED FEEDBACK
AND PROGRESSIVELY WITHOUT FEEDBACK
GREATER FOCUS ON FUNCTIONAL TASKS
REDUCED LEVELS OF ATTENTION
AND EFFORT REQUIRED
GOAL IS TO ACHIEVE AUTONOMOUS MOVEMENTS
AND EASE IN PERFORMING TASKS
LOWER FREQUENCY OF TREATMENT SESSIONS
KNEE
TREATMENT
PLAN SAMPLES
1

PATELLOFEMORAL PAIN SYNDROME PHASES 2

COGNITIVE ASSOCIATIVE AUTONOMOUS I II III IV V

1-2 4-6 2-4 WEEKS 1 2 3 6 3

1-4 4-12 2-4 SESSIONS DAILY DAILY 3 3 1-2

APPLICATIONS: EVALUATION, GENERIC, DYNAMIC STABILITY KNEE APPLICATIONS: ACL, POST-OP

EVALUATION
APPLICATION: 8 CHANNELS TO EVALUATE
AND COMPARE THE MAIN SUPERFICIAL MUSCLES
IN BOTH KNEES

ACL
APPLICATION: DESIGNED TO ASSESS
AND EXERCISE QUADRICEPS AND HAMSTRINGS
WITH AN ADEQUATE RATIO DYNAMIC STABILITY DYNAMIC STABILITY
PATELLOFEMORAL GENERIC
POST-OPERATIVE VERY INTUITIVE GRAPHICS WITH A BALANCE BAR
RECOVERY TO PROMOTE SIMILAR ACTIVATION BETWEEN
USEFUL FOR THE INITIAL STAGE OF TREATMENT,
TO GIVE AWARENESS OF THE STABILIZER MUSCLES
ONE CHANNEL APPLICATION: INDICATED WHEN VMO AND VL INDICATED TO USE ON A MORE ACTIVATION
THE AIM IS TO FOCUS IN A SINGLE MUSCLE ACTION ADVANCED STAGE

1 Clinical Reasoning
2 Almeida, 2005
 KNEE
MOTOR PATELLOFEMORAL PAIN SYNDROME

RELEARNING
PROGRESSION
OBJECTIVES
1

COGNITIVE STAGE ASSOCIATIVE STAGE AUTONOMOUS STAGE

RESTORING THE CONTRACTION LEVELS OF THE  MAINTAINING THE SAME LEVELS OF MAINTAINING CONTRACTION IN DIFFERENT
VMO IN ORDER TO INCREASE THE VMO/VL RATIO  CONTRACTION IN DIFFERENT POSITIONS DAILY ACTIVITIES, WITH GOOD CONTROL ACROSS
(1:1) 2 AND ALSO ONSETS OF BOTH MUSCLES AND WITH LOW FEEDBACK THE MOVEMENT
 
OCCURING SIMULTANEOUSLY 3 4 5.
(JUST WATCHING THE GRAPHICS IN CASE OF THE GOAL IS TO DECREASE FEEDBACK LEVELS
A 5ms DELAY IN VMO ACTIVATION IS ASSOCIATED  GREAT NEED) UNTIL NO FEEDBACK IS NEEDED
WITH A SIGNIFICANT INCREASE IN LATERAL 
PATELLOFEMORAL JOINT LOADING 4.
STABILIZERS (VMO AND VL) SHOULD PRE ACTIVATE 
THE MAIN MOBILIZER (RECTUS FEMORIS).
ACTIVATION FIRST WITH FEEDBACK AND WHEN 
WELL EXECUTED, WITHOUT FEEDBACK

1 Fitts & Posner, Cit. By Wulf, 2007
2 Souza & Gross, 1991 Cit. By Ng, Zhang & Li, 2008
3 Ng, Zhang & Li, 2008
4 Cowan, Bennell, Hodges; Crossley & Mcconnell, 2003
5 Kushion, Rheaume, Kopchitz, Glass, Alderink And Jinn, 2012

ACTIVATION TIMINGS
E.1

MOVEMENT ASSESSMENT
ACT. TIMING MVC ACT. TIMING MVC

1 -0.15 ms 0.40 v superior

vastus medialis
trapezius
1 -82.0
10.0ms
ms 0.25 v
stabilizers

vastus medialis
ASSESS

UNCOORDINATED UNBALLANCED
vastus lateralis 2 -0.15 ms 0.40 v inferiorlateralis
vastus trapezius
2 509.0
-5.0 ms 0.40 v
COMMON
serratus anterior
PATIENT ISSUES
mobilizer

rectus femoris 3 0.0 ms 0.45 v rectus femoris 3 0.0 ms 0.45 v

(representative values)

BOTH STABILIZER MUSCLES SHOULD PRE-ACTIVATE USUALLY PATIENS HAVE AN OVER ACTIVATION OF VASTUS
THE MOVEMENT AND SHOULD ALSO ACTIVATE LATERALIS COMPARING TO VASTUS MEDIALIS AND ALSO
SIMULTANEOUSLY WITH A BALANCED LEVEL OF A LATE ACTIVATION OF VASTUS MEDIALIS
ELECTRIC ACTIVITY
 REST ASSESSMENT

TREATMENT

TREATMENT
STIMULATE WITH EXERCISE

MVC

1
stabilizers
vastus medialis 0.00 v 100% >10% 100% <15% 100%

80 80 80
vastus lateralis 2 0.00 v
60 60 60
mobilizer

40 40 40

rectus femoris 3 0.00 v 20

>10%
20
<15%
20

0 0 0
17% 17%

vastus medialis vastus lateralis rectus femoris

MUSCLES AT REST SHOULD HAVE A RESIDUAL USUALLY PATIENTS HAVE VASTUS MEDIALIS LOW USUALLY PATIENTS HAVE VASTUS MEDIALIS WITH
ACTIVATION OR NON ACTIVATION ACTIVITY UNBALLANCED WITH VASTUS LATERALIS VERY LOW LEVELS OF ELECTRICAL ACTIVITY, WHICH
MEANS IS NOT VERY ACTIVE COMPARING WITH

MOTOR
VASTUS LATERALIS

RELEARNING RECOMMENDED EXERCISES

PROGRESSION •gentle isometric contractions focused on VMO in sitting position, with knee flected in various ranges between 0
and 90º; in the same position, push the ground without movement of the feet; foot in external rotation, without

EXERCISES
1 leaning back in the chair, push the ground again (cognitive stage);
(suggestions) •as a progression, we move to standing position: gait simulation, with symptomatic side steping forward, with
progressive higher load and repeat this movement; squats 2 legs first and only one after (associative stage);

COGNITIVE STAGE •move to increased knee flexion activities, as climbind and descend stairs, with increased higher stairs; daily
functional activities; running (autonomous stage).
SHOULD REPEATEDLY PERFORM THE EXERCISE
FOR 10s x 10s1, APPLYING THE SAME STIMULUS
FOR NO LONGER THAN 5 MINUTES 
AS THE ANTECIPATORY OR FEEDFORWARD 
POSTURAL RESPONSES OCCUR IN ADVANCE
ASSOCIATIVE STAGE AUTONOMOUS STAGE
OF A MOVEMENT, THEY MUST BE PREPLANNED ADD MOVEMENT TO THE TRAINING PLAN, CHECK IF THE PATIENT IS ABLE TO PERFORM
BY THE CENTRAL NERVOUS SYSTEM STARTING WITH SMALL RANGES MULTIPLE TASKS WITH CONTROL OF THE STABILIZERS
A STRATEGY TO RETRAIN NORMAL COORDINATION  OF ANALYTICAL MOVEMENTS IN DIFFERENT POSITIONS & SPEED OF MOVEMENT
INVOLVES VOLUNTARY ACTIVATION OF THE  START PROGRESSIVELY TO ADD RESISTANCE ADD FUNCTIONAL MOVEMENTS AND TRAIN THEM
SPECIFIC MUSCLES THAT ARE AFECTED BY PAIN,  TO THE MOVEMENT, USING AN ELASTIC RUBBER IN DIFFERENT WAYS
DURING FUNCTIONAL MOVEMENTS2

1 Santos e Matias, 2007

2 Cowan, Bennel, Hodges; Crossley & MacConnell, 2003
3 Kushion, Rheaume, Kopchitz, Glass, Alderink And Jinn, 2012
 KNEE
ACL POST-OP 12
ACL POST-OP RECOVERY

RECOVERY PHASES
THE FOLLOWING PROTOCOL WAS DEFINED ACCORDING TO THE PHYSIOLOGICAL RECOVERY PHASES OF THE LIGAMENT. HOWEVER, IS POSSIBLE TO
CO-RELATE THESE STAGES WITH THE MOTOR RELEARNING STAGES, DEFINED BY FITTS & POSNER, USED IN ALL THE OTHER TEMPLATES.

WE START THE INTERVENTION BY GIVING AWARENESS OF THE ACTIVITY OF THE VMO AND AWARENESS OF THE HAMSTRING, TRAINING THESE
ACTIVATIONS IN SEPARATE (COGNITIVE STAGE). AFTER THIS WE LOOK FOR A CO-ACTIVATION OF QUADS AND HAMS (ASSOCIATIVE STAGE).

IN THE END OF THE INTERVENTION, WE LOOK FOR A FUNCTIONAL RESPONSE, BY PERFORMING DAILY TASKS (AUTONOMOUS STAGE).

PHASE I PHASE II PHASE III

POST-OP
1ST WEEK
GOALS
- CONTROL EDEMA AND PAIN
- ACHIEVE A GOOD MOBILITY OF PATELLOFEMORAL
JOINT
- KNEE FLEXION BETWEEN 75º & 90º AND A GOOD
NEURO MOTOR CONTROL OF THE QUADRICEPS
- PRIORITY IS TO ACHIEVE FULL EXTENSION
OF THE KNEE
ACTIONS
DAY 0-5
- ICE THERAPY
- MOBILIZATION OF PATELLOFEMORAL JOINT
- GAIT WITH 2 CRUTCHES
- FLEXION TO AL LEAST 90º WHILE SITTING FOR MEALS
- REST WITH LIMB ELEVATION, CHANGING FROM ICE
THERAPY TO CONTINUOUS PASSIVE MOTION (CPM)
FROM 0-90º, TILL HOSPITAL DISCHARGE
- SHORT-ARC QUADRICEPS MUSCLE EXERCISES WITH A
ROLL UNDER THE KNEE - BIOFEEDBACK
MONITORIZATION OF THE VMO, TO GIVE
AWARENESS ABOUT IT'S ACTIVATION - USE
POSTOPERATIVE RECOVERY APP/ BIOFEEDBACK
GENERIC APP/ ACL APP (FOCUS ON THE
QUADRICEPS)
BETWEEN
2ND & 3RD WEEK
GOALS
- CONTROL EDEMA AND PASSIVE RANGE OF MOTION OF
EXTENSION/FLEXION (0-100/115º) AND ACTIVE (0-90º)
- GAIT WITH PARTIAL LOAD > 50% OF THE BODY WEIGHT,
WITH SUPPORT OF ONE CRUTCH AND NO SUPPORT IN
THE END OF THE PHASE
- MUSCULAR STRENGHT OF IN MAXIMUM 60% DEFICIT IN
THE QUADRICEPS AND 35% IN THE HAMSTRINGS
WHEN COMPARING WITH THE HEALTHY LIMB
- PROPRIOCEPTION IMPROVEMENT
ACTIONS
- REPETITION OF THE PREVIOUS PROCEDURES
- SPECIFIC TECNIQUES FOR RANGE OF MOTION
IMPROVEMENT
- TRAINING WITH SCALES TO VERIFY % OF LOAD
- MUSCULAR STRENGTHENING WITH ISOMETRIC
CONTRACTIONS OF QUADRICPES AND HAMSTRINGS
AT 0, 30, 60 AND 90º, FLOOWED BY MANUAL
RESISTENCE, INSISTING IN CO-CONTRACTIONS
BETWEEN Q/H, TAKING IN ACCOUNT THE ACTIVE
ARCH OF MOVEMENT FROM FLEXION TO EXTENSION
BETWEEN 100-45º TO AVOID TENSION ON THE
PLASTY - BIOFEEDBACK TRAINING OF Q AND H IN
SEPARATE AND WITH CO-CONTRACTION – USE ACL
APP, WORKING Q AND H ISOLATED AND THEN BOTH
AT THE SAME TIME
BETWEEN
4TH & 6TH WEEK
GOALS
- CONTROL EDEMA & PASSIVE RANGE OF MOTION OF
EXTENSION/FLEXION (0-120/135º) & ACTIVE (0-120º)
- MUSCULAR STRENGHT OF IN MAXIMUM 40% DEFICIT IN
THE QUADRICEPS AND 20% IN THE HAMSTRINGS WHEN
COMPARING WITH THE HEALTHY LIMB
- PROPRIOCEPTION AND DYNAMIC STABILITY
IMPROVEMENT
- AVOID STRESS IN THE PLASTY
- GAIT WITH 100% OF LOAD & WITH NO COMPENSATIONS
ACTIONS
IN THE END OF THIS PHASE THE NEO-LIGAMENT IS IN
THE END OF THE NECROSIS PERIOD, AND SO, ALL THE
ACTIONS SHOULD BE INTRODUCED ACCORDING TO
THE INFLAMATORY ANSWER.
- REPETITION OF THE NEEDED PREVIOUS PROCEDURES
- BIPODAL STABILIZATION TRAINING, BALANCE AND
GAIT - BIOFEEDBACK MONITORIZATION OF Q AND H
DURING THE TASKS, RECRUITING DIFFERENTLY THE
GROUPS ACCORDING TO THE AMPLITUDE OF
MOVEMENT – USE ACL APP
- STEP-UPS AND MINI-SQUATS - BIOFEEDBACK
MONITORIZATION OF Q AND H DURING THE TASKS,
RECRUITING DIFFERENTLY THE GROUPS ACCORDING
TO THE AMPLITUDE OF MOVEMENT – USE ACL APP
- HEEL DROPS, WITH A TOWEL/ROLL IN THE AQUILES
TENDON REGION AND THE PATIENT IN SUPINE; GOAL
IS TO PRESS THE TOWEL IN ORDER TO MOVE THE
KNEE AWAY FROM THE GURNEY, TRAINING
HAMSTRING MUSCLES AND EXTENSION AMPLITUDE –
USE BIOFEEDBACK GENERIC APP/ ACL APP (FOCUS
ON THE HAMSTRINGS)
- PRONE HANG, WITH THE MID PART OF THE THIGH
SUPPORTED ON THE END OF THE GURNEY (AVOIDING
KNEE CONTACT WITH THE GURNEY), WORKING
EXTENSION BY GRAVITY ACTION AND FROM THIS
POSITION, RECRUIT HAMSTRINGS BY BENDING AND
EXTENDING THE KNEE – USE BIOFEEDBACK GENERIC
APP OR ACL APP (FOCUS ON THE HAMSTRINGS)
DAY 5-8
- MOBILIZATION OF PATELLOFEMORAL JOINT
- ANKLE FLEXION/EXTENSION WITH ELEVATION
- PASSIVE MOBILIZATION IN OPEN KINETIC CHAIN
- GAIT WITH NO LOAD, BUT WITH SUPPORT – TRAIN
WITH 2 WALKING AIDS (BIOFEEDBACK
MONITORIZATION OF THE VMO, TO START TO GIVE
AWARENESS ABOUT IT'S ACTIVATION)
- PROPRIOCEPTION TRAINNING IN CLOSED KINETIC
CHAIN WITH A BALL ON THE WALL - (BIOFEEDBACK
MONITORIZATION OF THE VMO, TO GIVE AWARENESS
ABOUT IT'S ACTIVATION) – USE POSTOPERATIVE
RECOVERY APP/ BIOFEEDBACK GENERIC APP/ ACL APP
(FOCUS ON QUADRICEPS)
- CO-CONTRACTIONS OF QUADRICEPS AND
HAMSTRINGS, SEATED, WITH THE LIMB SUPPORTED -
BIOFEEDBACK MONITORIZATION OF BOTH MUSCULAR
GROUPS TO WORK ON A GOOD RATIO OF
ACTIVATION) – USE ACL APP
- ELECTROSTIMULATION ALTERNATE WITH BIOFEEDBACK
EXERCISES
1 Shelbourne & Gray, 1997
2 Almeida, 2005
- ELECTROESTIMULATION OF THE QUADRICEPS
- STRETCHING OF THE HAMSTRINGS
- PROPRIOCEPTION TRAINING WITH BALANCE
PLATFORMS IN THE END OF THIS PHASE WHEN PAIN
IS CONTROLLED - BIOFEEDBACK MONITORIZATION
OF BOTH GROUPS TO ENSURE A CORRECT
PARTICIPATION DURING THE EXERCISE – USE ACL APP
TO CONTROL RATION BETWEEN Q/H
- GAIT TRAINING TO LEAVE CRUTCHES
PHASE IV
BETWEEN
7TH & 12TH WEEK
GOALS
- ACHIVE RANGE OF MOTION EXTENSION/FEXION
0-130/135º, WITH END-FEEL CLOSE OH THE
CONTRALATERAL KNEE
- MUSCULAR STRENGHT OF IN MAXIMUM 35% DEFICIT
IN THE QUADRICEPS AND 15% IN THE HAMSTRINGS
WHEN COMPARING WITH THE HEALTHY LIMB AND
ACHIEVE A GOOD STABILITY AND PROPRIOCEPTION.
ACTIONS
- REPETITION OF THE NEEDED PREVIOUS PROCEDURES
- MUSCULAR STRENGTHENING BY PERFORMING
EXERCISES AS SQUATS, LUNGES, LEG PRESS, GAIT
TRAINING WITH ELASTIC RUBBER, SINGLE LIMB DEAD
LIFT - BIOFEEDBACK MONITORIZATION OF Q AND H
DURING THE TASKS, RECRUITING DIFFERENTLY THE
GROUPS ACCORDING TO THE AMPLITUDE OF
MOVEMENT – USE ACL APP
- FLEXIBILITY/ STRETCHING
- TREADMILL RUNNING AT 10TH WEEK - BIOFEEDBACK
MONITORIZATION PAYING SPECIAL ATTENTION TO
THE LANDING PHASE– USE ACL APP
- TRAINING OF UNIPODAL STABILIZATION -
BIOFEEDBACK TRAINING OF Q AND H
CO-CONTRACTION - USE ACL APP
- PLYOMETRIC EXERCISES (LATERAL, FORWARD,
BACKWARD HOPS OVER CONE; SINGLE LEG HOPS
OVER CONE; VERTICAL JUMPS; SCISSORS JUMPS) - 
BIOFEEDBACK MONITORIZATION OF Q AND H
CO-CONTRACTION WITH SPECIAL ATTENTION TO
LANDING PHASE - USE ACL APP
- BICYCLING
- EXERCISES IN CLOSED KINETIC CHAIN WITH TOTAL
LOAD TO POTENTIATE Q AND H (LEG PRESSES AND
SQUATS) - BIOFEEDBACK MONITORIZATION OF Q
AND H DURING THE TASKS, RECRUITING DIFFERENTLY
THE GROUPS ACCORDING TO THE AMPLITUDE OF
MOVEMENT – USE ACL APP
- EXTENSION/FLEXION ALMOST TOTAL RANGES OF
MOTION (0-135º) AND TOTAL LOAD OF THE LIMB.
PHASE V
BETWEEN
13TH & 15TH WEEK
GOALS
- MUSCULAR STRENGHT OF IN MAXIMUM 30% DEFICIT
IN THE QUADRICEPS AND 10% IN THE HAMSTRINGS
WHEN COMPARING WITH THE HEALTHY LIMB AND
PROPRIOCEPTION CLOSE TO NORMAL
- IN THE FINAL OF THIS PHASE IS POSSIBLE TO START
SPORTS, WITHOUT CONTACT, IF ALL GOALS WERE
ACHIEVED
ACTIONS
- REPETITION OF THE NEEDED PREVIOUS
PROCEDURES
- READAPTATION TO THE SPECIFIC SPORT GESTURE –
IN THIS PHASE IS VERY IMPORTANT TO MAKE SURE
ALL THE PREVIOUS MOTOR LEARNINGS ARE
CONSISTENT AND ALLOW A CORRECT
PERFORMANCE IN THE SPORT GESTURE OR ANY
OTHER FUNCTIONAL ACTIVITY – USE ACL APP
- SPORT ACTIVITY WITHOUT CONTACT
AT HIS TIME THE INTERVENTION PROGRAM IS OVER, SINCE
THE PATIENT HAS A FUNCTIONAL LIMB, ACCORDING TO THE
HEALTHY SIDE.
CAN START GYM EXERCISES AND SPORT ACTIVITY WITH NO
CONTACT. SHOULD RETURN EVERY MONTH TILL 6 MONTH
OF SURGERY.
CONTRAINDICATIONS
PLACEMENT OF THE SURFACES ON DAMAGED
SKIN (OPEN WOUND OR BURN).
Note: Biofeedback is less effective in teaching motor
control with those with cognitive impairment.
The therapist should decide if the level of impairment
makes it a useful tool for treatment.
Anyway, physioplux can remain useful for assessment
in this cases.
 APPLICATIONS
MOST FREQUENTLY USED

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shoulder pain
work-related neck pain
chronic pain
repetitive strain injury
fibromyalgia
arthritis
urinary incontinence
fecal incontinence
stroke
subacromial impingement syndrome
glenohumeral instability
low back pain
headache
patellofemoral pain syndrome
levator ani syndrome
ACL ligamentoplasty

1 Santos e Matias, 2007

2 Clinical Reasoning
BIBLIOGRAPHIC
REFERENCES
Cowan S, Bennell KL, Hodges PW, Crossley KM, McConnell
J. Simultaneous feedforward recruitment of the vasti in
untrained postural tasks can be restored by physical therapy.
J Orthop Res 2003; 21(3):553-8.

Kushion D, Rheaume J, Kopchitz K, Glass S, Alderink G, Jinn

J. EMG Activation of te Vastus Medialis Oblique and Vastus
Lateralis During Four Rehabilitative Exercises. The Open
Rehabilitation Journal 2012; 5:1-7.

Ng G, Zhang A, Li C. Biofeedback exercise improved the

EMG activity ratio of the medial and lateral vasti muscles in
subjects with patellofemoral pain syndrome. J
Electromyography and Kinesiology 2008; 18(8):128-133.

Santos C and Matias R (2007) – Descrição de um Plano de

Intervenção da Fisioterapia num sujeito com Síndrome do
Conflito Sub-Acromial, com auxílio de Biofeedback
Electromiográfico: Estudo de Caso. Setúbal. [s.n.], Projecto
de Investigação, Intervenção da Fisioterapia nas Disfunções
do Complexo Articular do ombro. 215.

Wolf, G (2007) – Attention and Motor Skill Learning.

ISBN – 13: 9780736062701.

Almeida I. Protocolo de Recuperação Após Ligamentoplastia

O.T.O. do LCA. EssFisiOnline 2005; 1(2):26-39.

Shelbourne K, Gray T. Anterior Cruciate Ligament

Reconstruction with Autogenous Patellar Tendon Graft
Followed by Accelerated Rehabilitation. The American
Journal of Sports Medicine 1997; 25(6):786-705.