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EMG Biofeedback andInsensitivity

Ric, Julie, Francesca

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EMG Biofeedback- review

Technique enabling the individual to readily determinethe activity levels of a particular physiological process,

and with training learn to control this process with aninternalized mechanism. Results must require an effort from the patient. Muscle electrical signals (EMG record) translated to

audio and visual stimuli through the use of a braincomputer interface (BCI) or thought translation device.

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How EMG Biofeedback works!

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EMG Biofeedback

Visual and auditory stimuli are controlled through gain settingsand thresholds.High gain settings = Sensitive (see results, and lower frustration)Low gain settings = Less Sensitive

Treatment of paralysis often involves both settings

Thresholds allow for therapists to control how much EMGactivity must be present for activation of biofeedback.

-paralyzed muscle tissue often shows small EMG

activity; high gain settings coupled with the use ofthresholds prevent biofeedback signal from thisactivity

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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)

- Inexpensive1st session = $300 Additionalsessions = $150- Non-invasive

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Electrode Placement

Surface electrodes record broad activity

Distant muscle signal is lessened due to impedance ofmuscle fibers

Proximity is important but it is impossible to know exactlywhat muscle fibers are being recorded (often placed 2

apart parallel to dominant muscle fiber)

Improved technology allows for more accurate readings as

low as .08V (myoscan and myotrac)

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EMG uses with insensitivity

CNS:- hemiplegia- results from stroke causing paralysis inone side of the body

-paraplegia /quadriplegia- results from nervedamage or severe injury to CNS causing paralysis in

extremities-Amyotrophic Lateral Sclerosis (ALS)wasting awayof muscle due to inactivity and scaring of motor neurons

-Cerebral Palsy- paralysis resulting from brain injurybefore, during, or shortly after birth

Peripheral:-Bells Palsy- facial paralysis resulting from damaged

neurons-Injury- any damage of peripheral neurons resulting

from injury

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Paralysis Study (injury)

Dr. Brucker (1996)- 100 long term spinal cord injury patientswith no improving muscle activity in triceps (within subjectsdesign)

All patients received 45 mins of BFT for tricep extensions-75 of 100 receive additional treatments

EMG data shows significant improvement after 1 session andincreased improvement with each subsequent treatment

Biofeedback is effective for increasing voluntary EMG responsesin this sample.

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ALS Lou Gehrigs Disease progressive neurodegenerative disease

effecting motor neurons in CNS

Mind often remains unaffected but can no longer control motorfunctions (lack of myelin sheath)

Symptoms:- muscle weakness in speechand breathing (60%)- twitching/cramping inhands/feet

- thinning/impairment ofarms/legs-thick speech, lowprojection

- complete paralysis

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ALS- a challenge to biofeedback

EMG useful for diagnosis, problematic forrehabilitation

Damage of nerve cells prevents EMG improvement

without some miracle drug biofeedback cannotrepair such a problem

Fortunately, ALS doesnt invade the mind. This means

EEG biofeedback can be used to translate thoughts

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Cerebral Palsy and Biofeedback

Non-degenerative chronic disorder impairing musclecontrol

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 recovery

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Conversion Paralysis and EMG

Uncommon neuro-dysfunctional condition resultingfrom psychological conflict in stress and sporadicepisodes

Patient convinces himself that an extremity has nosensation or movement.

Treatment:

- Fishbain (1988) 4 patients with conversionparalysis were successfully treated with BFT-EMG record showed significant improvementof functional capacity in afflicted extremities

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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)

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/biofeed1.htm

http://www.bio-medical.com/news_display.cfm?mode=EMG&newsid=26

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Facial and VocalParalysis Rehabilitation

using EMG

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Outline

General information about EMG

Facial Paralysis Rehabilitation Vocal Paralysis Rehabilitation

Interesting Applications of EMG biofeedback inrelation to paralysis

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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

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Facial Rehabilitation

Treatment Techniques:

exercise, electrical stimulation, biofeedback, andneuromuscular retraining for facial paresis

Sunderland third-degree injuries benefit mostfrom EMG therapy

Muscle re-education using surface EMGbiofeedback and home exercises is efficient intreatment of facial palsies

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EMG treatments also useful for:

poliomyelitis

cerebrovascular accidentstorticollis

nerve injury

temporomandibular joint syndromebruxism and other disorders

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The effectiveness of neuromuscular facialretraining combined with electromyographyin facial paralysis rehabilitationTested 24 patients over a 2 year period

After retraining using EMG stimulation, facialmuscle control improved by 2 levels.

Concluded:

facial retraining exercises and EMG are effective forimproving facial movements post paralysis

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EMG rehabilitation of facial function andintroduction of a facial paralysis grading scale forhypoglossal-facial nerve anastomosis.

30 patients with no facial muscle control Developed 6 point grading scale established to assess

improvementTen patients (33%) achieved the highest possible grading (II)

with symmetry and synchrony of function and spontaneity ofexpression; 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

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Facial Reanimation With Jump Interpositional GraftHypoglossal Facial Anastomosis and Hypoglossal Facial

Anastomosis

Classically managed with HFA but this has negative sideeffects

The JIGHFA with gold weight lid implantation and (EMG)rehabilitation offered as alternative

18 JIGHFA patients compared with 30 HFA with EMGpatients

JIGHFA resulted in substantial facial reinnervation in 83.3%of the patients without hemilingual sequelae which was seenin 45% of the HFA patients

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Vocal Paralysis: What is it?

Vocal fold paralysis and paresis result from abnormalnerve input to the voice box muscles (laryngealmuscles).

Paralysis is the total interruption of nerve impulseresulting in no movement of the muscle

Paresis (also possible) is the partial interruption ofnerve impulse resulting in weak or abnormal motion oflaryngeal muscle(s).

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Vocal Paralysis What nerves are involved?

Superior Laryngeal Nerve (SLN): carries signals tothe cricothyroid muscle which adjusts vocal cordtension for high/low pitches

Recurrent Laryngeal Nerve (RLN): signals todifferent voice box muscles responsible for opening

vocal folds (as in breathing, coughing), closing vocal

folds for vocal fold vibration during voice use, andclosing vocal folds during swallowing.

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Vocal Paralysis

Not simply inability to speak

Can also affect: ability to swallow

cause shortness of breath

noisy breathing

hoarseness

unclear breathy voice

breath use in sound production

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Vocal Paralysis

How is it diagnosed?

Laryngeal electromyography (LEMG):measures electrical currents invoice box muscles resulting from nerve input information.

Measuring and looking at patterns in electrical currents showwhether there is repair of nerve inputs (re-innervation) andthe extent of the nerve lesion or problem. It works through theinsertion of small needles that can measure electrical currents inthe vocal cord muscles. In LEMG testing, patients perform a

number of tasks that would normally produce typical activity inthe vocal muscles.

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Vocal Paralysis

So, the EMG technique is useful in evaluating patientswith 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 symptomsof progressive neurological diseases such as myastheniagravis.

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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 therapeuticinjections into the laryngeal muscles, and as an assessment

tool in the evaluation of the causes of vocal fold paresis 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.

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Interesting Applications

The utilization of EMG biofeedback for thetreatment of periorbital facial muscle tension

Reduced firing in upper and lower eye, reported

reduced tension after 20 sessions

3 months later, subjects reported completeelimination of all muscle tension in orbital area

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Interesting Applications

Crocodile Tear Syndrome

botulinum toxin treatment under EMG

guidance

Rare complication of facial paralysis

carry out the injection of botulinum toxin underEMG guidance in order to inject botulinum toxin

selectively into the lacrimal gland to protectpalpebral, lateral rectus, and superior rectus muscles.

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Sources

Cronin GW. (2003). The effectiveness of neuromuscular facial retraining combined withelectromyography 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. (all)Hammerschlag, Paul E. MD (1999) Facial Reanimation With Jump

Interpositional Graft Hypoglossal Facial Anastomosis and Hypoglossal FacialAnastomosis: 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 speechgestures following neural anastomosis. J Speech and Hearing Disorders. Feb:43(1): 9-20.

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Sources

Novak C. (2004). Rehabilitation Strategies for Facial NerveInjuries. 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. 37(1):105-19

Paniello RC. (2004). Laryngeal Reinnervation. Otolaryngol Clin.North Am. 37(1): 161-81.

Kizkin S. (2005). Crocodile Tears Syndrome: Botulinum ToxinTreatment under EMG Guidance. Funct. Neurology. 20(1): 35-7.

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Stroke

Ischemic ~ 80% of all strokes

Blood vessel blocked

Thrombotic

Embolic Systematic Hypoperfusion

Venous Thrombosis

HemorrhagicBlood vessel ruptures

Intracerebral

Subarachnoid

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Paralysis

Hemiplegia

Paralysis on one side of body

Lesion in corticospinal tract

Contralateral motor control

Hemiparesis

Weakness or partial paralysis

Less severe than Hemiplegia

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Electromyography

Only 5% regain full motor control

20% dont regain any function

Significantly lower EMG in agonistic musclesgroups

No difference in antagonistic muscles

Treatment should target motor neuron recruitment

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EMG Biofeedback

Visual or auditory signals

Computer games

Strengthen agonist

muscle groups Relax/inhibit antagonist

muscle groups

Gait training

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Stroke Treatment

Motor copy biofeedback training

EMG biofeedback from unaffectedmuscles

Train patients to produce matching activity in paretic

muscles

Longer-lasting results than typical biofeedback group

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Stroke Treatment

Constraint-inducedmovement therapy

Restrain functional limb

so that patient is forced toretrain weak muscles

Progress monitored byTMS mapping of primarymotor cortex

Combined with EMGStimulation

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Functional Tone Management

Helps patients regainhand function

Current studies

monitoring corticalreorganization

Incorporate EMGrecording to measure

improvement?

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References

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: 428-443.

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.strokeassociation.org/presenter.jhtml?identifier=3029938

http://en.wikipedia.org/wiki/Stroke#Signs_and_symptoms

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