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EMG Biofeedback and Insensitivity


EMG Biofeedback and Insensitivity Ric, Julie, Francesca EMG Biofeedback- review Technique enabling the individual to readily determine the activity levels of a ... – PowerPoint PPT presentation

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Title: EMG Biofeedback and Insensitivity

EMG Biofeedback and Insensitivity
  • Ric, Julie, Francesca

EMG Biofeedback- review
  • Technique enabling the individual to readily
    determine the activity levels of a particular
    physiological process, and with training learn to
    control this process with an internalized
  • Results must require an effort from the patient.
  • Muscle electrical signals (EMG record) translated
    to audio and visual stimuli through the use of a
    brain computer interface (BCI) or thought
    translation device.

How EMG Biofeedback works!
EMG Biofeedback
  • Visual and auditory stimuli are controlled
    through gain settings and thresholds. High gain
    settings Sensitive (see results, and lower
    frustration) Low gain settings Less Sensitive
  • Treatment of paralysis often involves both
  • Thresholds allow for therapists to control how
    much EMG activity must be present for activation
    of biofeedback. -paralyzed muscle tissue often
    shows small EMG activity high gain settings
    coupled with the use of thresholds prevent
    biofeedback signal from this activity

Biofeedback as Treatment
  • EMG has been used since early 60s to help
    diagnose and treat neuromuscular disorders such
    as paralysis.
  • Therapists integrate EMG with other interventions
    for best results
  • Advantages - Increase self reliance of patient
    during rehab (empowerment) - Inexpensive 1st
    session 300 Additional sessions 150 -

Electrode Placement
  • Surface electrodes record broad activity
  • Distant muscle signal is lessened due to
    impedance of muscle fibers
  • Proximity is important but it is impossible to
    know exactly what muscle fibers are being
    recorded (often placed 2 apart parallel to
    dominant muscle fiber)
  • Improved technology allows for more accurate
    readings as low as .08µV (myoscan and myotrac)

EMG uses with insensitivity
  • CNS - hemiplegia- results from stroke causing
    paralysis in one side of the body - paraplegia
    /quadriplegia- results from nerve damage or
    severe injury to CNS causing paralysis in
    extremities -Amyotrophic Lateral Sclerosis
    (ALS) wasting away of muscle due to
    inactivity and scaring of motor
    neurons -Cerebral Palsy- paralysis resulting
    from brain injury before, during, or shortly
    after birth
  • Peripheral -Bells Palsy- facial paralysis
    resulting from damaged neurons -Injury- any
    damage of peripheral neurons resulting from

Paralysis Study (injury)
  • Dr. Brucker (1996)- 100 long term spinal cord
    injury patients with no improving muscle activity
    in triceps (within subjects design)
  • All patients received 45 mins of BFT for tricep
    extensions -75 of 100 receive additional
  • EMG data shows significant improvement after 1
    session and increased improvement with each
    subsequent treatment
  • Biofeedback is effective for increasing voluntary
    EMG responses in this sample.

  • Lou Gehrigs Disease progressive
    neurodegenerative disease effecting motor neurons
    in CNS
  • Mind often remains unaffected but can no longer
    control motor functions (lack of myelin sheath)
  • Symptoms - muscle weakness in speech and
    breathing (60) - twitching/cramping in
    hands/feet - thinning/impairment of arms/legs
    - thick speech, low projection - complete

ALS- a challenge to biofeedback
  • EMG useful for diagnosis, problematic for
  • Damage of nerve cells prevents EMG improvement
    without some miracle drug biofeedback cannot
    repair such a problem
  • Fortunately, ALS doesnt invade the mind. This
    means EEG biofeedback can be used to translate

Cerebral Palsy and Biofeedback
  • Non-degenerative chronic disorder impairing
    muscle control
  • Physical and occupational therapy allow for
    independence of patient
  • EMG biofeedback used for speech improvement and
    better control of voluntary movements
  • Like ALS, biofeedback is not sufficient in

Conversion Paralysis and EMG
  • Uncommon neuro-dysfunctional condition resulting
    from psychological conflict in stress and
    sporadic episodes
  • Patient convinces himself that an extremity has
    no sensation or movement.
  • Treatment - Fishbain (1988) 4 patients with
    conversion paralysis were successfully treated
    with BFT -EMG record showed significant
    improvement of functional capacity in afflicted

  • Asfour, S., Fishbain, D., Goldberg, M., Khalil,
    T. (1988). Utility of electromyographic
  • biofeedback for the treatment of conversion
    paralysis. American-Journal-of- Psychiatry. Vol
    145(12), 1572-1575
  • Berkow, Robert (1997). Merck Manual of Medical
    Information. New York Pocket Books.
  • Brucker BS and Bulaeva NV (1996). Biofeedback
    effect on electromyography responses in
  • patients with spinal cord injury. Arch Phys Med
    Rehabil. 77 (2) 133-7.
  • The ALS Association. (2006) lthttp//www.alsa.org/gt
  • Elder, S.T. (1982) Amyotrophic lateral sclerosis
    A challenge for biofeedback. American-
  • Journal-of-Clinical-Biofeedback 5(2), 123-125.
  • http//www.electrotherapy.org/electro/biofeedback/
  • http//www.bio-medical.com/news_display.cfm?modeE

Facial and Vocal Paralysis Rehabilitation using
  • General information about EMG
  • Facial Paralysis Rehabilitation
  • Vocal Paralysis Rehabilitation
  • Interesting Applications of EMG biofeedback in
    relation to paralysis

EMG in Medicine
  • Two Methods
  • Subdermal Needle EMG Surface EMG
  • Used in Voluntary Muscle Control
  • Reduction of activity and restoration of activity
  • Used to alleviate muscle tension
  • Applications for migrane headaches

Facial Rehabilitation
  • Treatment Techniques
  • exercise, electrical stimulation, biofeedback,
    and neuromuscular retraining for facial paresis
  • Sunderland third-degree injuries benefit most
    from EMG therapy
  • Muscle re-education using surface EMG biofeedback
    and home exercises is efficient in treatment of
    facial palsies

Facial Rehabilitation
  • EMG treatments also useful for
  • poliomyelitis
  • cerebrovascular accidents
  • torticollis
  • nerve injury
  • temporomandibular joint syndrome
  • bruxism and other disorders

Facial Rehabilitation
  • The effectiveness of neuromuscular facial
    retraining combined with electromyography in
    facial paralysis rehabilitation
  • Tested 24 patients over a 2 year period
  • After retraining using EMG stimulation, facial
    muscle control improved by 2 levels.
  • Concluded
  • facial retraining exercises and EMG are
    effective for improving facial movements post

Facial Rehabilitation
  • EMG rehabilitation of facial function and
    introduction of a facial paralysis grading scale
    for hypoglossal-facial nerve anastomosis.
  • 30 patients with no facial muscle control
  • Developed 6 point grading scale established to
    assess improvement
  • Ten patients (33) achieved the highest possible
    grading (II) with symmetry and synchrony of
    function and spontaneity of expression 17 (57)
    reached grade III, which allowed voluntary
    control of eye and mouth function 3 (10) showed
    minimal gains lasting between 3 and 18 months

Facial Rehabilitation
  • Facial Reanimation With Jump Interpositional
    Graft Hypoglossal Facial Anastomosis and
    Hypoglossal Facial Anastomosis
  • Classically managed with HFA but this has
    negative side effects
  • The JIGHFA with gold weight lid implantation and
    (EMG) rehabilitation offered as alternative
  • 18 JIGHFA patients compared with 30 HFA with EMG
  • JIGHFA resulted in substantial facial
    reinnervation in 83.3 of the patients without
    hemilingual sequelae which was seen in 45 of the
    HFA patients

Vocal Paralysis What is it?
  • Vocal fold paralysis and paresis result from
    abnormal nerve input to the voice box muscles
    (laryngeal muscles).  
  • Paralysis is the total interruption of nerve
    impulse resulting in no movement of the muscle
  • Paresis (also possible) is the partial
    interruption of nerve impulse resulting in weak
    or abnormal motion of laryngeal muscle(s).

Vocal Paralysis
  • What nerves are involved?
  • Superior Laryngeal Nerve (SLN) carries signals
    to the cricothyroid muscle which adjusts vocal
    cord tension for high/low pitches
  • Recurrent Laryngeal Nerve (RLN) signals to
    different voice box muscles responsible for
    opening vocal folds (as in breathing, coughing),
    closing vocal folds for vocal fold vibration
    during voice use, and closing vocal folds during

Vocal Paralysis
  • Not simply inability to speak
  • Can also affect ability to swallow
  • cause shortness of breath
  • noisy breathing
  • hoarseness
  • unclear breathy
  • breath use in sound

Vocal Paralysis
  • How is it diagnosed?
  • Laryngeal electromyography (LEMG) measures
    electrical currents in voice box muscles
    resulting from nerve input information. Measuring
    and looking at patterns in electrical currents
    show whether there is repair of nerve inputs
    (re-innervation) and the  extent of the nerve
    lesion or problem.   It works through the
    insertion of small needles that can measure
    electrical currents in the vocal cord muscles. In
    LEMG testing, patients perform a number of tasks
    that would normally produce typical activity in
    the vocal muscles.

Vocal Paralysis
  • So, the EMG technique is useful in evaluating
    patients with vocal cord paralysis
  • Can pinpoint specific lesioning in unexplained
    vocal paralysis
  • Also can be used with other vocal disorders such
    as spasmodic dysphonia, vocal tremors, and the
    symptoms of progressive neurological diseases
    such as myasthenia gravis. 

Vocal Paralysis
  • Electromyography and the immobile vocal fold
  • Laryngeal EMG functions as a prognostic tool in
    the evaluation of vocal fold paralysis, as a
    guide for therapeutic injections into the
    laryngeal muscles, and as an assessment tool in
    the evaluation of the causes of vocal fold
  • Laryngeal EMG in the paralyzed vocal fold can
    guide diagnosis and treatment by pointing to the
    site of the lesion
  • Guides management of and evaluation of motion
    disorders of larynx.

Interesting Applications
  • The utilization of EMG biofeedback for the
    treatment of periorbital facial muscle tension
  • Reduced firing in upper and lower eye, reported
    reduced tension after 20 sessions
  • 3 months later, subjects reported complete
    elimination of all muscle tension in orbital area

Interesting Applications
  • Crocodile Tear Syndrome
  • botulinum toxin treatment under EMG guidance
  • Rare complication of facial paralysis
  • carry out the injection of botulinum toxin under
    EMG guidance in order to inject botulinum toxin
    selectively into the lacrimal gland to protect
    palpebral, lateral rectus, and superior rectus

  • Cronin GW. (2003). The effectiveness of
    neuromuscular facial retraining combined with
    electromyography in facial paralysis
    rehabilitation. Otolaryngol Head Neck Surg -
    01-APR-2003 128(4) 534-8
  • Brundy, J., Hammerschlag PE, Cohen NL, Ransohoff
    J. (2002). Electromyographic rehabilitation of
    facial function and introduction of a facial
    paralysis grading scale for hypoglossal-facial
    nerve anastomosis. Department of Rehabilitation
    Medicine, New York University School of Medicine.
  • Hammerschlag, Paul E. MD (1999) Facial
    Reanimation With Jump Interpositional Graft
    Hypoglossal Facial Anastomosis and Hypoglossal
    Facial Anastomosis Evolution in Management of
    Facial Paralysis. Laryngoscope. 109 (2, Part 2)
    SUPPLEMENT NO. 90 1-23.
  • Daniel B, Guitar B. (1978). EMG Feedback and
    Recovery of facial and speech gestures following
    neural anastomosis. J Speech and Hearing
    Disorders. Feb 43(1) 9-20.

  • Novak C. (2004). Rehabilitation Strategies for
    Facial Nerve Injuries. Seminars in Plastic
    Surgery. 18 47-51.
  • Sulica L. (2004). Electromyography and the
    immobile vocal field. Otolaryngol Clin. North
    Am. 37(1) 59-74.
  • Miller S. (2004). Voice Therapy for Vocal Fold
    Paralysis. Otolaryngol Clin. North Am.
  • Paniello RC. (2004). Laryngeal Reinnervation.
    Otolaryngol Clin. North Am. 37(1) 161-81.
  • Kizkin S. (2005). Crocodile Tears Syndrome
    Botulinum Toxin Treatment under EMG Guidance.
    Funct. Neurology. 20(1) 35-7.

  • Ischemic 80 of all strokes
  • Blood vessel blocked
  • Thrombotic
  • Embolic
  • Systematic Hypoperfusion
  • Venous Thrombosis
  • Hemorrhagic
  • Blood vessel ruptures
  • Intracerebral
  • Subarachnoid

  • Hemiplegia
  • Paralysis on one side of body
  • Lesion in corticospinal tract
  • Contralateral motor control
  • Hemiparesis
  • Weakness or partial paralysis
  • Less severe than Hemiplegia

  • Only 5 regain full motor control
  • 20 dont regain any function
  • Significantly lower EMG in agonistic muscles
  • No difference in antagonistic muscles
  • Treatment should target motor neuron recruitment

EMG Biofeedback
  • Visual or auditory signals
  • Computer games
  • Strengthen agonist muscle groups
  • Relax/inhibit antagonist muscle groups
  • Gait training

Stroke Treatment
  • Motor copy biofeedback training
  • EMG biofeedback from unaffected muscles
  • Train patients to produce matching activity in
    paretic muscles
  • Longer-lasting results than typical biofeedback

Stroke Treatment
  • Constraint-induced movement therapy
  • Restrain functional limb so that patient is
    forced to retrain weak muscles
  • Progress monitored by TMS mapping of primary
    motor cortex
  • Combined with EMG Stimulation

Functional Tone Management
  • Helps patients regain hand function
  • Current studies monitoring cortical
  • Incorporate EMG recording to measure improvement?

  • Fritz, S. L., Chiu, Y., Malcolm, M.P., Patterson,
    T.S. and Light, K.E.. (2005) Feasibility of
    electromyography-triggered neuromuscular
    stimulation as an adjunct to constraint-induced
    movement therapy. Physical Therapy  85.5
  • Barker, E. (2005). New hope for stroke patients
    a new therapy offers hope that movement will be
    restored to weakened limbs following a
    stroke. RN  68.2 38-44.
  • Gowland, C., deBruin, H., Basmajian, J.
    V., Plews, N., and Burcea, I.  Agonist and
    antagonist activity during voluntary upper-limb
    movement in patients with stroke.  Physical
    Therapy  72.n9 624-634.
  • "A Rehab Revolution," Stroke Connection
    Magazine, September/October 2004http//www.stroke
  • http//en.wikipedia.org/wiki/StrokeSigns_and_symp
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