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 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 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 settings 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 - Non-invasive

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 .08V (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 injury

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 treatments 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.

ALS
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 paralysis

ALS- a challenge to biofeedback

EMG useful for diagnosis, problematic for rehabilitation 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 thoughts

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 recovery

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 extremities

References
Asfour, S., Fishbain, D., Goldberg, M., & Khalil, T. (1988). Utility of electromyographic biofeedback for the treatment of conversion paralysis. American-Journal-ofVol 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) <http://www.alsa.org/> Elder, S.T. (1982) Amyotrophic lateral sclerosis: A challenge for biofeedback. AmericanJournal-of-Clinical-Biofeedback 5(2), 123-125. http://www.electrotherapy.org/electro/biofeedback/biofeed1.htm Psychiatry.

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

Facial and Vocal Paralysis Rehabilitation using EMG

Outline
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 paralysis

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 patients 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 swallowing.

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

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 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.

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 muscles.

Sources
Cronin GW. (2003). The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otolaryngol Head Neck Surg - 01APR-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 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.

Sources
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. 37(1):105-19 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.

Stroke
Ischemic ~ 80% of all strokes
Blood vessel blocked
Thrombotic Embolic Systematic Hypoperfusion Venous Thrombosis

Hemorrhagic
Blood vessel ruptures
Intracerebral Subarachnoid

Paralysis
Hemiplegia
Paralysis on one side of body Lesion in corticospinal tract Contralateral motor control

Hemiparesis
Weakness or partial paralysis Less severe than Hemiplegia

Electromyography
Only 5% regain full motor control 20% dont regain any function Significantly lower EMG in agonistic muscles groups
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 group

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 reorganization Incorporate EMG recording to measure improvement?

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 2004 http://www.strokeassociation.org/presenter.jhtml?identifier=3029938 http://en.wikipedia.org/wiki/Stroke#Signs_and_symptoms