WYYYWV Chapter 11 Electromyographic Biofeedback to Improve Voluntary Motor Control Stuart A. Binder-Macleodinformanon (tecdback) to an individual about a physiological function or re uvcdiwy ‘he in dividual then attempts to alter the feedback signal in order to modify the physiological response (1). Though the clinical appheation of biofeedback in cludes the use of the clectromvograph (EMG), the clectroeneephalograph (EEG), blood pressure, heart rate, and visceral and vasomotor responses, the present chapter will address only the application most widely used in physical rehabilitation—EMG biofeedback. EMG biofeedback is the use of electronic instrumentation to detect and feed back the myoclectric signals from skeletal muscle in order to allow the patient to gain better volitional control over the muscle. EMG bioteedback is used to train patients to relax hyperactive mus cles or to increase the discharge rate and number of motor units activated to merease the strength of contraction, This chapter discusses the advantages of using biofeedback, technical con- siderations regarding the application of EMG biofeedback, selection of ap- propriate patients for the applicanion of EMG bioteedback, and development of training strategies during the use of EMG biofeedback. Advantages of Using EMG Biofeedback EMG biofeedback ts not a trearment, Rather, it ss atoobthareclinicianscan use to help their patients lear new tasks or modify existing motor patterns by prowidimng usctul information both to the clinician and parent (sec Fig. 111). The actual treatment is the activities or exercises that patients perform, To lustrate this point, parallels may be drawn berween the use of a mirror during posture training and the use of biofeedback, One would never say that the mirror is being used to treat a patient, Rather, the murror is merely a tool that is used to provide feedback to the patient, Similarly, in EMG biofeedback, the clectromyographic signal is a tool that clinicians and patients use to provide information about the electrical activity of specific muscles. One advantage of EMG biofeedback is the speedsand»continuitywath wineh the information is prowded to the chmaan and parent. Without biofeedback clinicians must rely on palpation or visual inspection to deter- mine if the appropnate muscles are being recruited or relaxed during an exercise. At best, the detection, processing, and formulation of a response by the health care worker takes several hundred milliseconds. Given the ephemeral nature of most motor responses, by the time the patient receives and processes the verbal or manual feedback that the clinician provides, the patient may be performing at a very different level than was orginally per- cenved by the chnician. Rew feedbackete be effective it must be coincidental withthe task thabastobemodified. EMG bioteedback can be nearly instan- tanoous, thus reflecting the existing state of muscle contracnon. Kelated to the speed of processing information is the ability of the EMG biotcedback to provide continuous feedback. If verbal feedback requires several hundred milliseconds to be processed and presented to the patient, the fastest rate that verbal feedback could be updated and presented to the patient would be one to two times per second. In contrast, most biofeedback machines can inform patients of their responses in a nearly continuous manner 435436 Chapter 11 Electromyographic Biofeedback * Identify task ® Verbal fecdback ® Motivation EMG input Ritecdhack equipment Figure 11.1 Schematic representateen of flow of information berween panent, therapiet, and hwntcedback eqpuspenent The sensitivity, objectivity, accuracy, in| quantitative nature ol the teedbacksignal are also major advantages of EMG biofeedback. Only with biofeedback can relatively subtle changes in the recruitment of muscles be detected, Small changes in motor unit recruitment are parncularly difficult to detect with palpation or visual inspection when patients are contracting at either high or low force levels. Knowledge of these subtle changes, however, may be necessary to allow pauents to make appropriate changes in recruit- ment. For example, if a muscle contains relatively few active motor units, duc to either a peripheral or central nervous system problem, the recruitment may not be sufficient to produce any joint displacement. The activity in the mus- cle would thus be very difficult to detect or quantify by the clinician without EMG biofeedback. The use of manual detection and verbal feedback to train moter unit recrumment may not reflect the true changes in the recruitment, Even if small increases in motor wnit recruitment are produced, clinician sen- sitivity may not detect the change, and appropriate positive feedback may not be prowided. On the other hand, positive verbal reinforcement in the ab- sence of additional recruitment during maximal effort also is not effective in recruitment traning. In contrast, EMG bioteedback is ts and actual level.ot rocrumment, EMG biotecdback 1s also jcet'sefiort. The quantitative nature of EMG feedback clearly shows which cflorts serve to increase recruitment and which efforts show less recruitment. The clinician can objectively observe which techniques or activities really help recruimment and when the panent is beginning to fangue. Modern feedback devices can provide a vanety 0 that can serve to motivate the client. These signals range from the “raw” or unprocessed visual and auditory EMG signal, to tones whose frequencies increase or decrease in proportion to the level of EMG activity, to computerre. . a Clinical Electrophysiology 437 controlled images on a video display terminal. In addition, bioteedback de- vices can be used to turn on or off other clectromic devices, such as radios or tape recorders, which can be used as positive reinforcements for young children, Technical Considerations Regarding the Application of EMG Biofeedback This section reviews the factors that determine the amplitude of the EMG, outlines the rationale tor specitic clectrode selection and placement, discusses the method and purpose of cach step in the processing of the EMG feedback signal, and presents the vanous methods of displaying the biofeedback signal and the advantages /indicanions for each, The BMG is the recording of the electrical activity of the muscle membrane inanbaeinhiobealtpesensd Sitestanal tes. The ieuel ot the EMG reflects theszeand nember of active motorunies as well as the ! . Although no direct information is contained within the EMG regarding the foree or torgue that a muscle produces, a mearhe linear relationship does exist berween the LMG and the toree that a muscle produces under caretully controlled mamemccundmoans (2, 3). The clinician should be aware, however, that this linear relanionship no longer holds when contractions change from isometric to nonisometric or as the muscle fatigues. Similarly, because the EMG only records from a limited area of a muscle, the EMG cannot be used to com. pare the strength of contraction across muscle groups or even within the same muscle if different clectrode placement or types of electrodes are used (see be- low), To illustrate this concept, recording electrodes may be applied over the abductor digiti minimi muscle of one person and over the quadriceps femoris muscle of another, Depending on the electrode size and spacing, the electri. cal activity from the abductor of one subject’s little finger may approximate the activity trom the other subject's knee extensor dunng volinonal activation despite the marked differences in force output berween the two muscles. In addition to physiological factors, such as the size and number of active motor units, the size of the recording area and the interelectrode distance of the recording clectrodes also affect the amplitude of the EMG. ‘Pheclarger the recording arca, the greater the vohime of muscle that = monttored and ~ hence the greater the bMG- recorded Similarly, the larger the interelectrode distance, the larger the volime of muscle that is monitored and the larger the EMG. Thus, to increase the specificity of the EMG recording clectrodes, small recording areas and close interelectrode spacing could be used, The tise of close spacing thus minimizes the recording of electrical activity from muscles other than the targeted muscle. This may be particularly helptul if the EMG from the targeted muscle is being contaminated by input from a mus- cle that is an antagonist of the targeted muscle. This phenomenon is termed eros talk. such as fine wire clectrodes, are examples of small, closely spaced electrodes that allow precise localization from within the muscle. Subcutancous clectrodes also offer the advantage of being able to record from deep muscles without interference from more superficial muscles and show greater sensitivity than surface electrodes duc438 Chapter 1!_—_Electromyographic Biofeedback ro their proximity to the active muscle fibers. Skin, subcutaneous fat, and fascia all serve to attenuate the EMG recorded by surface clectrodes. Never- theless, inserted clectrodes are rarely used with EMG biofeedback (4). Gur tacerelectrades arc much more convenient for the clinician, more acceptable ro the panent, and produce much less movement artifact than subcutaneous clectrodes. Movement artifact is the high-voltage, nonphysiological contam- ination of the EMG due to the physical perturbation of the clectrodes, input cables, and wires. To minimize the recording from unwanted muscle groups, the spacing between the recording electrodes should be as small as is practi- cably possible. Interelectrode spacing of one to two centimeters is generally adequate, Essentially, fivessteps are involved im the processing of the EMG feed- back signal: ammpliicarion, flrering: reeuhcanen, mtegranon, and lewebderee tion, The processes of amplification, filtering, and integration are discussed in Chapter 10, A schematic representation of the changes in the EMG biofeed- back signal is shown in Figure 11.2. Most feedback devices allow the chnician to modify most of these processes. The amplification, gain, or sensitivity are all terms used to describe the relationship between the input and output voltages of the ampliticr. Dhe-greater the ampliheaneny the moresensitive the deviec. That 1s, with a high ampliication, even very small EMG signals pro- duce discernible changes in the output displayed to the patient. In general, the greatest sensitivity that does not saturate the ourput signal is used. When training a patient to increase recruitment, and given a choice of sensitivities from an output meter of 10, 100, of 1000 pV to produce full-scale deflec- tion, if the patient has a maximum recruitment of 80 pV, then the best choice would be the 100-yV sensitivity. peeraea Integrated Level detected Figure 11.2 Schematic representation of the proceming of the EMG signal,Clinical Electrophysiology 439 recording clectrodes and a reference electrode. Also, the use of close spacing between the recording clectrodes serves to help minimize the noise recorded and give the cleanest signal possible, Thus, particularly when attempting to record low levels of clectrical activity, close spacing is used to minimize the noise that would be amplified. The filtering characteristics of most feedback devices can be modified. By “pliner, we can attempt to reduce nowse and make the recording more selec ‘tive, Movement artifact tends to be low frequency (< 100 Hz), and much of the clectronic noise is high trequency (> 1000 Hz). Because most of the EMG signal falls within the 100 to 1000 Hz range, this is the range most of- ten used. However, if high-frequency noise is a problem, narrower trequeney range may be required to climinate more of the high-frequency signal (¢.¢., only pass signal between 100 to 500 Hz). Because the EMG actually includes a fairly wide frequency range, the disadvantage of using a narrower frequency band is that some of the EMG js lost when a narrower range is used. There are times, however, when some of the EMG is purposely climinated, Because muscle attenuates high-frequency signals more than lower frequencies, the EMG signals from distant motor units are lower frequency than nearby motor units (5). Eliminating more of the low-frequency signal allows the amplifier to reduce the contnbution made by distant motor units to the EMG, Surface electrodes therefore become more selective (record from a narrower area) if the lower limit of the frequency band passed is raised. If the filtered output from a differential amplifier is fed into an audio speaker or oscilloscope, a mawekMG"is displayed. This is the used tersee the actial EMG or to listen for 60 TT interference . Having, ac- cess to the raw EMG is particularly helpful if there is a question of whether the processed feedback signal is of physiological origin or not. With modern amplifiers, even with surface clectrodes, single motor unit potentials can easily be identified. The next steps in the processing of the EMG are the rectification and integration of the signal. The signal needs to be full-wave rectified to be integrated (see Chapter 10 for an explanation). The integration of the sig- nal involves the summing of the signal over some penod of time, If a leaky capacitor is used to accomplish this task, what ts seen is a smoothing of the signal, as shown in Figure 11.2. Other integrators can be made to sum over a penod of time or until some preset maximum voltage is reached before the integrator is reset no zero. The rate at which the EMG sums and declines 1s a function of the time constant of the integrator. A short time constant will allow the integrated EMG to closely follow the peaks and valleys of the rect- fied signal. A longer time constant wall produce much greater smoothing of the signal and require a longer time for the integrated signal to reach its peak and a longer time to relax back to baseline. An integrated signal is required to display anything other than the raw EMG, Setting an appropiate time constant is important in producing an appro priate feedback signal. If the time constant is too short, the display (¢,p., a digital or analog voltage meter) will fluctuate too rapidly (display jitter), little sense can be made from such an output, In contrast, a time constant that is too long will cause the display to lag behind the actual activity of the muscle, As an440 Chapter 11 Electromyographic Biofeedback example, even if the sulyect relaxes, it may take several seconds for the display to return to zero, Neither of these situations is acceptable, An appropriate time constant will help te accurately reflect the overall state of activation of a muscle but will not show the wide and rapid fluctuations seen within the raw or rectitted EMG_ For most muscle training applications a time constant of approximately one-third of a second well. Nongerrime conetints ' in which the activity of a spe- cific muscle (c.g, frontalis muscle) is being used to reflect the overall state of relaxation of the panent. The last step in signal processing is the use of a thresholddetectortade a The ourput of a threshold detector is a binary function, that is, “on” or “off.” The logic of the ourput can be set to current the output, whatever it may be, to be on or off when the threshold is exceeded. For example, when training a young child with cerebral palsy to relax his plantarflexor muscle while standing at a table, the feedback can be set to allow an clectric train to min as long as the EMG is below a preset threshold, Whenever the EMG exceeds this threshold the train can be made to stop. The logic would thus have been set to give an on signal whenever the EMG voltage was below threshold and an off signal whenever the voltage exceeded the threshold. Many devices allow a combination of feedback signals, For instance, the output of the integrator may simultancously be sent to a light meter display (ie., asenes of lights is turned on) and a threshold detector. The meter can provide continuous visual feedback and the output of the threshold detector can be used to trigger an audio signal. Thus, the audio signal can be turned on when the threshold 1s exceeded. As already noted, the feedback signal’ can be raw or processed, auditory or visual, continuous or threshold-triggered. Within the limits of the available equipment, the clinician and patient must decide on the most appropriate sig- nal. The raw output (i.c., amplified and filtered only) can give the experienced clinician considerable information regarding the source of the signal, That is, is the source truly physiological, or is it primarily noise that is being recorded? Other than identifving the peak voltages from an oscilloscope screen, the raw signal cannot be quantified. This is a limitation when attempting to objec- tively document progress or to identify targeted levels of recruitment for the client. When deciding to use an auditory (e,¢., aw EMG, tone, or beep) or a visual display (e.g, diggral meter or light bar) patient preference and other practical factors need to be considered, Ifa lower extremity muscle is being monitored in preparation for ambulation training, auditory feedback may be preferred because visual feedback is not practical during ambulation (i.c., the patient needs to watch where he or she is going), Similarly, during relaxation training, most patients prefer auditery feedback because they may want to close their eves to help them relay. ‘The use of a threshold is necessary whenever EMG levels are used to tum on or off another dewee, such as a radio or tape player, The use of an audio threshold durmng targeted or general relaxation is also generally preferred. Most parents find the audio signal annoying and unnecessary if they are able to relax below the target. Only when the activity exceeds that target does the patient need to be alerted.Clinical Electrophysiology 44! As previously noted, more than one feedback signal can be used simulta- neously, especially if more than one muscle group is monitored, When two muscle groups are monitored simultancously (dual-channel monitoring), generally continous teedback is provided from one channel, whereas the other channel uses a threshold detector to “sound an alarm” only if the sec- ond muscle exceeds the threshold, This technique is commonly used when traning for recruitment of one muscle and relaxation of its antagonist. As an example, to train for increased active finger extension from a patient who shows spasticity as the result of cerebral vascular accident (CVA), the finger flexor and extensor muscles may be simultaneously monitored, Continuous auclitory and visual feedback to train for recraitment of the extensors could be provided while using a threshold detector to provide a separate auditory signal from the flexors. Only when the flexor activity exceeds a level that is believed to be interfering with finger extension would feedback from the flexors be provided to the patient. Selection of Appropriate Patients for the Application of EMG Biofeedback EMG biofeedback is one of the best-researched tools that is presently used in rehabilitation, Publications began appearing in the early 1960s supporting the use of EMG bioteedback in physical rehabilitation. The rate of publicanion reached its peak in the late 1970s and began to decline by the mid-1980s (6- 8). Although the most thoroughly investigated application of EMG biotced- back involves the treatment of patients following CVAs (8,9), numerous re- ports exist for the treatment of a plethora of conditions, including spinal cord injury, cerebral palsy, spastic torticollis, peripheral nerve injuries, low back pain, and ligament injuries. A review of the clinical efficacy of cach of these applicanons is beyond the scope of this chapter. Instead, the interested reader is referred to a number of related textbooks or review articles (1, 8), The selection of appropriate patients for the application of EMG biofeed- back basically involves answering the following three simple questions. . Does the patent demonstrate a motor impairment that would suggest that the informanion provided by the feedback would be of benefit? . Does the parent demonstrate the ability for voluntary contro? . Is the parent suthcrently motivated and cognitively aware to utilize the feedback information? One commen concern of clinicians is the amount of time required to pre. pare the patient (i.c., prepare the skin and apply the electrodes) and administer the biofeedback “treatment.” Thus, many clinicians who would agree that their paticnts would benefit from the information provided by EMG biofeed- back are reluctant to use the modality. Given the present quality of the amplifiers and filters used in most biofeedback devices and the availability of disposable self-adhering clectrodes, the time required for skin preparation and clectrode applicanon is minimum, In fact, recording an EMG from a subject may begin in as little as one minute after the individual is seated at a t» ble. Furthermore, consstent with the perspective that biofeedback should be442 ~Chapter!1 —_Electromyographic Biofeedback thought of as a tool and not an isolated treatment, specific training objectives can generally be reached faster with biofeedback than without. Admittedly, some additional, initial patient training is required to explain the purpose of the equipment. However, the information provided by most feedback signals IS SO INtUItIVe LO most panents that long or wordy explanationsare usually not necessary. A simple demonstration using an uninvolved muscle of the patient is usually sufficient. The advantages of this “faster learning” with the use of EMG biofeedback is most casily demonstrated in patients who have intact nervous systems yet, due te a pnor injury or trauma, are having a difficult time either recruiting or relaxing a specific muscle. One common clinical problem for which EMG biofeedback has been suggested is the inability of patients to recruit their vas- tus medialis muscles following knee surgery (10, 11). Biofeedback can be very helpful in quickly training a patient to perform a “quad set” (i.c., isometric contraction of the quadneceps femorns muscle with the knee in full extension) as well as training for greater quadriceps femons muscle recruitment during dynamic CXercises. In contrast, the use of EMG biofeedback with patients with impaired mo- tor control due to central nervous system pathology is much more difficult to demonstrate. Although numerous clinical reports and studies have supported the use of EMG biofeedback as a helpful rool to assist in the rehabilitation of patients with motor impairment due to CNS pathology (8, 9, 12-17), EMG biofeedback is not a treatment that can cure panents with CNS pathology, EMG biofeedback can help patients reach their true potential, but there are physiological limitations that both patients and clinicians must be aware of. For biofeedback training to be appropriate, the patient must have the po- tential to control the targeted muscle. The inappropriateness of the use of biofeedback training with patients with complete spinal cord injuries or com- plete peripheral nerve impairment prior to reinnervation by the peripheral nerve is Obvious. Other conditions may not make the selection of appropri- ate patients so apparent. Wolf and Binder-Macleod (16) demonstrated that in a group of patients who had sustained CVAs at least one year prior to treat- ment, only patients who demonstrated voluntary finger extension prior to the initiation of therapy were able to show any improvement in hand function as a result of 60 sessions using EMG biofeedback. That is, none of the panents who were unable to perform active finger extension prior to commencement of training demonstrated any improvement as a result of treatment. This sug- gests that at least a minimum amount of voluntary control must be present for patients to be able to use biofeedback to improve their function. How. ever, several of these patients who lacked even minimum finger extension did show improvement in shoulder, elbow, and wrist function. In addition to having the ability ro volitionally control a muscle, the panient must be motivated and have sufficient cognitive ability to learn to use the feedback signal. Training with the use of feedback is generally not a passive process; it requires the active participation of the patient, One exception ts when the clinician uses the EMG for his or her own feedback to determine the effectiveness of a particular intervention. For instance, a chnscian may use a Swiss ball to help reduce the tone in a young child with cerebral palsy, EMGClinical Electrophysiology 443 biofeedback delivered to the therapist could be used to provide quantitative information to the climecian if the specific techniques being used are actually producing the desired responses, Thus far only the appropriateness of EMG bioteedback has been discussed. Recently, other forms of feedback relevant to physical rehabilitation have been developed; these include the use of position and force feedback. In general, EMG biofeedback should be used when information regarding the activity of a specific muscle or muscle group is desired. As an example, if patients are very weak and little force or joint displacement is produced, position or force feedback would not be sufficiently sensitive to provide any meaningful intor- mation for these parents, EMG biofeedback is also generally most appropnate in situations where training specific muscles to relax while patients perform a particular task 1s desired. In contrast, the training of a specific muscle or muscke group may not be appropriate when the patient is trying to perform a task that requires the coordination of multiple muscle groups. For instance, when training a child with cerebral palsy to maintain proper head position, head position feedback would be much more helpful than EMG feedback trom any specific muscle group. Similarly, in the training of patients to shift their weight cither onto or off of an involved lower extremuty, force feedback, providing the exact amount of weight bearing by the involwed extremity, has been found to be most appropriate, Development of Training Strategies during the Use of EMG Biofeedback Although the information provided through the use of EMG biotcedback generally serves to motivate patients, because of its objective nature this in- formation can also serve as a source of frustration. Clinicians arc, therefore, encouraged to consider all factors related to learning theory when de- veloping their specific training strategics. Positive is better than negative re- inforcement when training patients. Obtainable short- and long-term goals must be clearly communicated to panents. Clinicians should listen to cach patient to be certain that the established goals are important to him or her. Experience has shown thar if patients are told to simply try their best, no matter how well they perform, they are always disappointed that they did not do better, In contrast, if specific tasks or goals are identified within and across sessions, then a real sense of accomplishment can be achieved. Tasks that demonstrate achievement of cach goal must be specific enough so that the patient knows all of the relevant conditions, and the criteria must be spe cific enough so that the patient knows when the task is accomplished, Qne i Several considerations need to be made regarding the sequencing or pro- gression of any treatment program. As an example, when treating a patient who has sustained a CVA, clinicians must decide if it is better to train for relaxation of spastic muscles prior to training recruitment of a weak antago- nist or if training should begin directly with weak or poorly recruited muscles.444 Chapter 11 Electromyographic Biofeedback Without the use of EMG biofeedback, exercises to train spastic muscles to relax are difficult to design and evaluate, As previously noted, the addition of EMG biofeedback makes the monitonng and training of spastic nvuscles much more objective and straightforward. For this reason, when using EMG biofeedback to train patients with disturbances in muscle tone, treatments have traditionally begun with training for relaxation of spastic muscles before working on recruitment of weak antagonist muscles (12-15). Recently, how- ever, the need for targeted relaxation training has been questioned (18, 19), Similar decisions regarding the progression of training need to be made con- cerning the choices to train (@) proximal muscles first and to then progress distally or to begin distally and progress proximally, (4) stability first and then progress to mobility training or reverse this order, or (¢) component move- ments first and then integrate the Components into a tanctional movement pattern or to commence training with functional movement patterns, These, as well as other choices, need to be made by clinicians based on their own treatment philosophy and as objective research findings support various ap- proaches to treatment. The use of biofeedback requires several addinonal consideranions regard- ing the progression of training, Should only one muscle group be moni- tored or should a dual-channel system be used? When should the parent be weaned from using the feedback signal? After all, the goal of training ts the performance of functional tasks without the use of biofeedback. Thus, the benefits of training with feedback need to be weighed against the long- term need to perform without feedback. One option would be to begin with a continuous feedback signal and progress to the use of some form of threshold feedback in an attempt to wean the patient from the need for any feedback. What level of success should the patient demonstrate before increasing the level of difficulty? That is, does a patient have to reach a targeted level of re- cruitment 100% or 50% of the time before we raise the targeted microvolt level that the patient is to achieve? These questions must be decided by the clinician during cach training session, Unfortunately, little objective informa- tion is presently available to help clinicians answer these and other relevant questions. The final strategy that will be considered is t \ . To record an EMG, the recording electrodes must be placed over or near the belly of the relevant muscle. In contrast, the placement of the reference electrode is not so crimecal. Some workers in this field have suggested that the reference clectrade be placed equidistant trom the two recording electrodes; however, the exact placement is not critical as long as good contact berween the skin and electrode is maintained (4). Neverthe- less, a number of factors, including goals of training, level of control, available muscle mass, subcutancous fat, movement artifact, and cross talk, must be considered when selecting the electrode sites. All of these factors interact, so it is impossible to determine the optimal electrode sites without considering all of them. As previously noted the greater the dirance et the recurdug cleetrodes tothe actwe duince, the greater the attenuation ot the bMG thar recorded: Also, MG. Thus, whenClinical Electrophysiology 445 Figure 11.3 Recommended place ment for recording from the antenue tibialis misebe placing clectrodes over a muscle, the following requirements must be met: . Areas that have a thickened layer of adipose tissuc must be avoided. . The distance between the recording electrodes and any muscles that are producing unwanted electrical activity (i-¢., cross talk) must be maxi mized, . The smallest interelectrode distance that is practical must be used. As an example, if the clinician wants to record from the anterior tibialis mus- cle, the best placement may be to have the recording electrodes less than one centimeter apart and ower the most medial aspect of the muscle (sec Fig. 11.3). This placement puts the recording electrodes over the targeted mus cle, while still being as far away as possible from other active muscles that may contaminate the intended feedback signal. Also, the clectrodes should be placed over the muscle when the linib is in the position that it will assume when the patient is performing the exercise. If a patient supinates his or her forearm while electrodes are placed over the fore- arm flexor muscle mass but then pronates his or her forearm during training, the electrodes may no longer be lying over the flexors; rather, the electrodes may now be over the brachioradialis muscle. In addition, electrodes and un shielded lead wires should be placed in a position so that they will not be jostled during training. This prevents movement artifact from contaminating the feedback signal. Within limits, if a panent has poor cc mtrol over a muscle, the mterelec trade distance can be used to advantage by sampling a larger or smaller area of the muscle. Ifa panent has difficulty recruiting from any of the heads of his or her quadnceps femons muscle, traming may begin using a relatively wide spacing to sample from a large portion of the muscle, However, care should be taken that the spacing iw not so wide that activity from the hip adductor or hamstring muscles is erroncously fed back to the patient. As the patient's446 Chapter 11! Electromyographic Biofeedback control increases, closer spacing may be used to monitor individual heads of the quadriceps femoris muscle, In contrast, if a patient displays spas nary and the goal is to train for relaxation of his or her finger and wrist flexors during passive stretch of the muscle to maintain range of motion, traning should begin with electrodes that are relanvely closely spaced, so as to limit the recording area. As the patient gains better control, a slightly wider spacing could be employed to sample more of the forearm flexor muscle Miss Case Studies Case | The patient is a 35-year-old male from India who contracted poliomyelitis at age 7. He has never received physical therapy. He now has severe foot-drop on the right side and wears a short leg beace (SLB). He is highly Birr would like to strengthen his ankle dorsiflenors to shed his brace. nostic testing reveals several amall motor units present in his anterior tibialis pe extensor digitorum longus muscles, No visible contraction of any of his ankle doruflexors can be observed. Assesment; Although the patient appears to be a good candidate for using EMG tofeedback to help increase motor unit recruitment, the probability for success 18 limited. Plan: 1. Initial treatment in the IT cline using EMG biofeedback to work on increased motor unit recruitment 2. Assess progress and evaluate patient for use of portable EMG bioleedback for independent home training 3. After visible contractions can be produced, begin on resistive strengthen- ing program Detailed Treatment Plan: Mode of feedback: Initially provide both auditory and visual EMG biofeed: back. Make the transition to auditory feedback prior to gait training with the feedback, Short-term goal of training: Yo increase EMG from targeted muscles. Will set specific targeted levels of recruitment to encourage an increase in the discharge rare of already active motor units and to attempt the recruitment of additional motor units. Electrode placement: Over the ankle dorsiflexor muscles, Moderately wide interelectrode distance. Could monitor plantartlexors to determine if cross tulk i a problem, Dieration of trearment: To patient tolerance. Whea EMG recruitment ev. cls begin to decline, the patient is fariguing. Allow patient to rea. When recowery from fatigue is incomplete, terminate treatment.Clinical Electrophysiology 447 Case 2 The client is a 56-year-old female who has been referred to PT for ROM ex- ercives for her right upper extremity. The client sustained a Colles’s fracture of her right wrist approxamately 6 months ago and maintained her entire mght arm nearly totally immobilized for the fint 3 months while in her cast, Following removal of her cast, the client presented with marked limitation in all active movements of her night shoulder, elbow, forearm, and wrist. The patient was then briefly instructed in an exercise program and followed by her surgeon, Due toa lack of progress in ROM, the client underwent a closed manipulation under anesthesia 2 weeks ago. The surgeon's report indicates that the client was able to achieve nearly full passive ROM in all joines. The client is presently alert, pleasant, and cooperative, though obviously at all joints during all active or passive movements. Asrsrment: Patient appears to be good candidate for EMG biofeedback for tar- Plan: 1. EMG biofeedback to promote relaxation and decrease splinting during passive ROOM to all affected joints 2. Compare EMG from involved and uninvolved upper extremitics during active ROM exercises to assess recruitment pattern 3. Train appropriate muscle groups to produce more “normal” recruitment levels during active ROM 4. Progress to functional training using EMG biofeedback to help normalize movements Mode of feedback: Initially provide both auditory and visual EMG biofced- back. Then have patient use signal that is most cffective. Short-term goal of traiming: To have patient display sumilar recruitment pat- tems from comparable involved and uninvolved muscle groups during pas- sive and active movements, Will set specific targeted levels of recruitment to train for either relaxation or recruitment. Electrode placcment: Over the targeted muscles. Narrow interclectrode dis- tance to increase recording specificity, Duration of treatment: Use EMG to indicate patient tolerance. When pa- nent begins to show decreasing ability to recruit or rclax muscles, terminate treatment to prevent patient from becoming frustrated. Summary The EMG can be ised by both the clinician and patient to help provide informanhon regarding the activation state of a muscle. EMG biofeedback is a valuable tool whose use should be considered by clinicians whenever a pa448 Chapter 11 —_ Electromyographic Biofeedback nent displays poor volitional motor control. Although a number of techni- cal and practical consideranons need to be taken into account when using EMG bioteedback, this tool can easily be incorporated into most traditional treatment approaches. Study Questions 1. Define biofeedback and discuss its advantages over simple verbal feed- back. 2. Identify the specific characteristics of the client that would suggest an appropriate use of EMG bioteedback. 3. Review the physiological factors that determine the amplitude of the raw EMG. 4. Identity the relationship between both the size and interelectrode dis- tance of the recording clectrodes to the amplitude and specificity of the EMG, >. Last each step in the processing of the EMG feedback signal, 6. Discuss the advantages and limitations of using the raw EMG during biofeedback training. 7. Identity the factors that need to be considered in selection of the ap- propriate sites for clectrade placement. References lL. Basmayan JV. Lotroduction. Principles and background. In; Basmajian JV, ed. Bioteedback: principles and practices for clinicians. 3nd ed. Balumore: Williams & Wilkins, 1989-14, 2. Lippeld OCT. The relationship between integrated acon potential in a human muscle and its semetnc tension, | Physiol 1952;117:492-499, 3. Bigland B, Lippold OC]. The relation between force, velocity and integrated electrical activity in human muscles, | Physvol 1954;123:214-224. 4. Basmapan [V, Bhuimenstein BR. Electrode placement in clectromyographic biofeedback. In: Basmajian JV, ed. Biofeedback: principles and practices for clinicians. 3rd ed. Baltumore: Williams & Wilkins, 1989-369- 382. 5, Clamann HP, Lamb RL. A simple cirewit for filtering single motor unit action potentials for clectrograms. Physiol Behav 1976,17:149-151. 6. Hatch PP, Saito 1. Growth and development of biofeedback: a bibhographic update. Riofeedback Self Regul 1990,15:37-46, 7. Hatch JP, Saito 1, Declining rates of publications within the fick! of biofeed: back continue: 1988-1991. Biofeedback Self Regul 1993,18-174. &. Wolf SL Electromyographic biofeedback applications to stroke patients: a cnt- wal rewew. Phys Ther 198363: 1448-1459 9 BKawnajan |V. Research foundations of EMG bioteedback in rehabilitation Hiedcedback Self Kegul 1988;13:275-298 10. Draper V. Bleetromyographic biofeedback and recovery of quadnceps femoris muscle function following antenor cruciate ligament reconstruction. Phys Ther 1990,70: 11-17, lL. Krebs DE. Climeal clectromyographic feedback following meniscectomy. A multiple regression expenmental analysis, Mhys Ther 1981 ,61:1017- 1021,