BIO-FEEDBACK

Hardik P Parab
Moderator: Preetha R John

Definition:
use of electronic instrumentation to provide objective information (feedback) to an individual about a physiological function or response so that the individual becomes aware of his or her response. Individual then attempts to alter the feedback signal in order to modify the physiologic response.

THERAPIST

PATIENT

BIOFEEDBACK INSTRUMENTATION

Middaughs conceptual framework for Biofeedback Therapy

Principle:

Motor learning:
Set of process associated with practice or experience leading to relatively permanent changes in capability for perform or respond.

Physiology of feedback:
Open loop control- pre planning Biofeedback in rehabilitationclosed loop control. Scheduled feedback- open + closed loop control

Technical limitation
Relevancy Accuracy Speed of information

FEEDBACK
INTRINSIC Bodys internal feedback mechanism which uses Visual Auditory Vestibular Proprioceptive EXTRINSIC Any feedback derived from an external source that augments intrinsic feedback. 2 types

KR Feedback given after performance of a task Related to overall result of task

KP Feedback given during or after performance of a task Related to how a 8 task was performed

Clinical application of biofeedback:

EMG EEG Blood pressure Heart rate Visceral & vasomotor response Biofeedback for neuromotor disturbances Biofeedback in stroke rehabilitation Combined behavioral therapy for hemiplegic arm & hand.

bf strategies of the OT in total hand rehabilitation BF with EMG in muscle reeducation BF in spasticity control BF with EMG in SCI Pts. BF with behavioral techniques in Rx of voluntary movement. BF training in pelvic floor & continence.

EMGBF in communication disorder Dental application of BF Therapeutic EMG in chronic back pain BF training of primary raynauds disease BF for psychotherapeutics application- general relaxation, headache Rx, general psychiatry, psychosomatic disorder.

Contraindication:
Absence of voluntary control Uncooperative Lack of understanding

EMG BIOFEEDBACK
EMG activity of a particular muscle group is presented in a visual or auditory form to a patient, who uses the feedback signal to learn discriminative control of the muscle.

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Electrode placement in EMGBF:

Temporalis, frontalis, masserter, zygomaticus & levator anguli

SCM

P. major

Deltoid

Serratus ant

Supraspinatus, trapezius, lats

Basic biofeedback circuit:AMPLIFIER

INTEGRATOR LEVEL DETECTOR

SIGNAL FILTER
RECTIFIER FEEDBACK DATA RECORD

CIRCUIT
Amplifier Filters A/D Converter CRT

G
Speaker

Patient

Stimulator
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Biofeedback in stroke rehabilitation

Main 3 typesEMG feedback Force feedback Position feedback

Combination of treatment.

 Preparation of clinicians Strong knowledge Anatomy & neurophysiology of rehabilitation program Biofeedback knowledge

Training strategies: Order of progression of treatment Goal selection Dual channel monitoring Supplemental techniques Weaning of biofeedback Training methods

 Multiple joint training clinical example Wrist & finger extensors Ankle dorsiflexors Position feedback for ankle Gait training

 EMG biofeedback & neuromuscular stimulation. Concurrent assessment of muscle activity (CAMA) Limb load monitor

Combined behavioral Rx for hemiplegics arm & hand: 1960 s biofeedback were started to use for hemiplegic arms Behavioral therapy programe + EMGBF Cognitive behavioral model- 4 phase Conceptualization Skill acquisition Skill rehearsal Skill transfer

Exercise physiotherapy Bobath concept Neurofacilitatory technique Fascilitatory + inhibitory technique

EMGBF in muscle reeducation:

Facial muscle- facial palsy Repair of facial palsy Nerve graft Nerve transfer Muscle transfer Dynamic + static procedure

 Facial nerve graft Masserter muscle transfer Gracilis transfer for anal incontinence

Gracilis for facial palsy or VIC

EMGBF in SCI patients

Traditional physiotherapy treatment for SCI patients EMGBF can be used to Identifying muscle with low measurable potentials Identify type of reflexely induced movement capable of producing measurable muscle contraction

 Evaluate improvement in muscle strength Provide feedback to patient & therapist during exercise

 Goal of treatment Reduce hypermotor response in spastic muscle When patient is able to reduce the response in supine , sitting & standing posture start to recruit the weak muscles. For paraplegicdecrease activity of adductors & calf increase activity of abd, lumbar paravert. Muscles, gluteus, rectus femoris, sartorius, hams & TA.

 Quadriplegic patientsincrease activity of upper trapezius, middle +ant deltoid, triceps, biceps, pect major, wrist +finger extensors in forearm. FES + EMGBF can be used for SCI patients.

Standing balance feedback:

 Posturography feedback Useful in treatment of Geriatric population patients with balance impairments Consists of force-measuring scales on which subject is requested to stand as still as possible COP COM

BF & other behavioral techniques in Rx of voluntary movement disorder

Isolated muscle involvement: Neck- spasmodic torticolis Jaw- oromandibular dystonia Muscle used in protective blinkingblepharospasm Writing- dystonic writers cramp Muscle of one side of face- hemifacial spasm

 EMGBF + behavioral control therapy Rx of dystonia spasmodic torticolisRx with cutaneous shock where pt wore position sensitive switch on head band which will +ed by head deviation. stimulation of head switch provide shock to finger tips & temporary reduction of shock will occur.

 Use of spasm- contingent cutaneous shock: EMGBF + spasm-contingent cut. Shock 2 electrodes will be applied to 1st 2 fingers of either hand Tactile biofeedback Rx of spasmodic torticollis: 4 channel surface EMG electrode During walking-portable EMGBF

 Hemifacial spasm EMGBF + spasm triggered cut. Shock Tremors EMGBF Parkinsonian symptoms: BF + progressive relaxation training + stress management training

 Facial rigidity (mask like face)- frontalis EMGBF Micrographia- extensor EMGBF Tremor (pill rolling movement)- flexor EMGBF.

Feedback goniometer in rehabilitation:

 Clinical goniometer: measure only spot measurementof joint angle & only contains of simple hinge. Feedback goniometer: measure continously changing joint angles to analyse complex motion of joint.

Finger goniometer Wrist goniometer Ankle goniometer Back goniometer Elbow goniometer Pronation-supination goniometer

Also measures Propioception & kinesthetic sensation.

Limb load monitor:

 Indication: Musculoskeletal Neurological Uses: For precise monitoring of partial weight bearing To provide an orderly progression in weight bearing To sustain max weight bearing To regulate postural & vestibular reaction

 Different studies had shown sensory feedback during locomotion improve more precise & sustain response. Can be done with 2 weight machines on parallel bar.

 Technical limitations Only the vertical ground reaction components are registered by LLMs LLMs may feedback invalid signals because before and after, torsional and horizontal sheer forces are not monitored separately in present devices Just an indication of gross errors in timing and weight bearing LLM provides only part of the picture with information on GRF

Head position trainer:

 For CP babies, child with torticollis & habitual head tilt. Made up of mercury cluster switch, ear phones & electronic buzzer. Head position monitor

Joint position trainer:

 Correction of hyperextension/ excessive flexion of knees To correct gait pattern in CVA patients CP babies- control jaw closure & drooling. Knee angle monitor: 2 parts Knee electrogoniometer (elgon) Control box

Treatment if communication disorders:

Doctors speech EMGBF: Decreased muscle tone- LMN disease Increased muscle tone- UMN disease Poor volitional control of incoordination- apraxia Dysarthria

Training of pelvic floor & incontinence:

BF in fecal incontinence:
Biofeedback RxSphincter exercise Training synchrony of internal & external sphincter Training discrimination of rectal sensation

Study- EMG signals with electrode mounted on a plug placed in anus has shown improvement in fecal incontinence. BF is Rx of choice in fecal incontinence.

Urinary incontinence:

Urinary incontinence:
Behavioral habits- biofeedback, habit training, bladder retraining, reinforcement of good toilet habit. Biofeedback will acts on 2 muscle groups in pelvic floor Bladder wall (smooth muscle) Pelvic flooor

 Kegel developed exercise plan + perineometer. Perineometer- biofeedback device. Study- EMGBF- in myelomeningiocele pts. training given with perineal electrode to pelvic floor & shown improvement in incontinence. Female micturition syndromeEMGBF improve coordination of detrusur & sphincter + increase urine outflow.

Pressure biofeedback
core muscle strengthening Pressure cuff, inflator, pressure reading indicator Maintain the pressure by contracting themuscle Gives visual feedback

References
Biofeedback-principles & practice for clinicians.-Basmajian. Physical rehabilitation- Susan b o sullivan
Electrophysiology by Robinson.