EMG Biofeedback and Insensitivity

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EMG Biofeedback and Insensitivity

• Ric, Julie, Francesca

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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.

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How EMG Biofeedback works!
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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

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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) - Inexpensive 1st
  session 300 Additional sessions 150 -
  Non-invasive

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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)

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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

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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.

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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 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

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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

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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

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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

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References

• 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/
  biofeed1.htm
• http//www.bio-medical.com/news_display.cfm?modeE
  MGnewsid26

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Facial and Vocal Paralysis Rehabilitation using
EMG
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Outline

• General information about EMG
• Facial Paralysis Rehabilitation
• Vocal Paralysis Rehabilitation
• Interesting Applications of EMG biofeedback in
  relation 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,
  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

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Facial Rehabilitation

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

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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

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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

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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

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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).

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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.

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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 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.

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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. 

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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 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.

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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

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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 under
  EMG guidance in order to inject botulinum toxin
  selectively into the lacrimal gland to protect
  palpebral, lateral rectus, and superior rectus
  muscles.

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Sources

• 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.
  (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.

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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.

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Stroke

• Ischemic 80 of all strokes
• Blood vessel blocked
• Thrombotic
• Embolic
• Systematic Hypoperfusion
• Venous Thrombosis
• Hemorrhagic
• Blood 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 muscles
  groups
• 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 unaffected muscles
• Train patients to produce matching activity in
  paretic muscles
• Longer-lasting results than typical biofeedback
  group

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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

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Functional Tone Management

• Helps patients regain hand function
• Current studies monitoring cortical
  reorganization
• Incorporate EMG recording 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.stroke
  association.org/presenter.jhtml?identifier3029938
  
• http//en.wikipedia.org/wiki/StrokeSigns_and_symp
  toms