Recent advances

Biofeedback in Motor
Recovery

PRESENTER: Priyanka Lalakia

MODERATOR: Dr. Selvam Ramachandran
Biofeedback
• Biofeedback is defined as the technique of using
electronic equipment to reveal to human beings the
internal physiological events, normal and abnormal, in
the form of visual and auditory signals in order to
teach them to manipulate these otherwise involuntary
and unfelt events by manipulating the displayed
signals

John Basmajian
Principle
• It is based on principle that improvements in motor
performance occur by facilitation of MOTOR
LEARNING

• Feedback is essential for learning to take place

• Biofeedback is a extrinsic type of feedback works on

principles of either knowledge performance(KP) or
knowledge of result(KR) or both

3
Types of biofeedback

-Oonagh M Giggins, et.al.

 Types of Neurological conditions
neuromuscular BFB in which BFB used

• EMG • Stroke
• Force plate • SCI
systems(Posturography • PD
feedback) • CP
• Kinematic (Joint • TBI
motion) Feedback/
• Bell’s palsy
Electrogoniometers
• Pressure biofeedback
• Force biofeedback
• Virtual reality
• EEG biofeedback
(Neurofeedback)
Objective

• To review the evidence for the various

biofeedback methods used for motor recovery
Search strategy
Databases:
• PubMed/Medline
• Cochrane Library

Search limits:
Search limits
Systematic reviews, Meta-
Study type
analysis, RCTs
Publication date Till October 2017

Language English
Search strategy: Key words &
Boolean Operators

“Motor
“Biofeedback” “Rehabilitation” “Stroke”
function”

AND AND AND

Alternative
OR OR Words OR OR

“Electromyography”
“Spinal cord injury”
“Posturography”
“Parkinson’s disease”
“Force platform”
“Facial palsy”
“EEG” “neurorehabili-
“Motor recovery” “Lower motor
“Virtual reality” tation”
neuron lesion”
“Pressure
“Cerebral palsy” 8
biofeedback”
Level of evidence
1A 1A = Systematic Review

1B 1B = RCTs
1C = All or None
Case Series
2A = Systematic
Review Cohort Studies
2B = Cohort Study/Low
Quality RCT
2C = Outcomes Research
3A = Systematic Review of Case-
Controlled Studies
3B = Case-controlled Study

4 = Case Series, Poor Cohort Case Controlled

9
5 = Expert Opinion
EMG Biofeedback
EMG biofeedback
• It is used to detect muscle action potentials from
underlying skeletal muscles that initiate muscle
contraction
• The myoelectric signals from the muscles are
translated in to simple sound and visual signals
-2009
Objective
• To determine the efficacy of any form of EMG-BFB
used after a stroke in order to aid motor function
recovery
Search strategy
• Databases searched: Cochrane Library,
MEDLINE, EMBASE, CINAHL, PsycINFO, First
Search

• Type of studies: RCTs and quasi-RCTs comparing EMG-

BFB with no EMG-BFB or sham EMG-BFB [1978-2003]

• Type of participants: Patients of any age or gender

with a clinical diagnosis of stroke

• Type of intervention: Surface EMG with the electrical

activity displayed to the patient in either a visual or
auditory format
• Type of outcome measures:
Primary outcome measure
-Change in muscle power relative to baseline
Secondary outcomes were:
-Change in electromyographic activity relative to the
baseline recording
-Change in range of motion relative to baseline
-Improvement in gait, measured by changes in stride
length, speed and changes in needs for ambulation
aids relative to baseline
-Change in function ability relative to baseline
-Proportion of subjects with muscle weakness due to
stroke
 Author Population Intervention/ Outcome
Comparison measures

Mroczek 9 participants (5 EMG plus physical •Active ROM at

1978 intervention, 4 control) therapy vs physical wrist
Between 1 and 10 years therapy alone •EMG potentials
post-stroke
Smith 1979 11 participants (6 Exercise program plus •Grading score of
intervention, 5 control) EMG-BFB or exercise gait from video
Patients at least 6 alone analysis
months from a stroke (1-hour sessions twice a •Patient
event with residual L.L. week for 6 weeks) questionnaires on
weakness but able to perceived sensory
walk short and motor function
distances of affected limb

Binder 1981 10 participants (5 in Physiotherapy alone vs Active ROM at

each group) physiotherapy plus EMG- ankle
At least 16 months from BFB Time to walk 50
stroke event 30 to 40-minute metres on both
treatment sessions 3 smooth and 17
times a week for 4 weeks carpeted surfaces
 Author Population Intervention/ Outcome measures
Comparison

Burnside •22 participants (11 in Exercise program plus •Muscle strength of

1982 each group) EMG-BFB or exercise tibialis anterior
•Mean time from stroke plus placebo EMG-BFB (MRC scale 0 to 5)
of 4.8 years 15-minute sessions •Active ROM at
twice a week for 6 ankle
weeks •Basmajian’s rating
scale for gait

Inglis 1984 30 participants (15 in 20 sessions of EMG- •Brunnstrom

each group) BFB plus Stages of recovery
Mean time of 19 months physiotherapy or
post-stroke physiotherapy alone

Lee 1985 26 participants (13 in Physiotherapy alone vs •Active ROM at wrist

each group) physiotherapy plus and ankle
Mean time from stroke EMG-BFB •EMG potentials
5.1 months
18
 Author Population Intervention/Comp Outcome
arison measures

Mulder 1986 12 participants (6 in each Physiotherapy alone •Active range of

group) vs physiotherapy plus movement at
Patients at least 6 months EMG-BFB ankle joint
from a stroke event with 40-minute sessions 3 •EMG potentials
residual L.L. weakness but times a week for 5 •Analysis of gait
able to walk short distances, weeks
adequate mental function

Basmajian 29 participants (13 Physiotherapy alone Upper Extremity

1987 intervention, 16 control) vs physiotherapy plus Function Test
Mean time from stroke 16 EMG-BFB Finger Oscillation
weeks 45-minute sessions 3 Test
times a week for 5
weeks
Cozean 1988 16 participants (8 in each Physiotherapy alone Stride length
group) vs physiotherapy plus Gait cycle time
Mean time from stroke not EMG-BFB Angles of knee
stated 30-minute sessions 3 and ankle during
19
times a week for 6 walking
weeks
 Author Population Intervention/ Outcome measures
Comparison

Crow 1989 40 participants (20 in each Physiotherapy alone vs Brunnstrom-Fugl

group) physiotherapy plus Meyer test
Between 2 and 8 weeks EMG-BFB Action Research
poststroke Arm test

Intiso 1994 16 participants (8 in each EMG plus physical Barthel, Canadian,

group) but 2 fromthe therapy vs physical Adams, Basmajian
control group did not therapy alone and Ashworth scales
complete the used
rehabilitation program Stride length and
Mean time from stroke 9.8 gait speed
months
Bradley Data available for a total of Physiotherapy plus Time taken and
1998 21 participants (12 EMG-BFB vs number of steps to
intervention, 9 control) physiotherapy alone do a 10 metre
Mean age 70 years Rivermead mobility
Mean time from stroke 36 index
days ROM at ankle 20
Nottingham
extended ADL index
 Author Population Intervention/ Outcome
Comparison measures

Armagan 27 participants (14 Exercise program Brunstrom’s

2003 intervention, 13 control) plus EMG-BFB or Stages of Hand
Mean time from stroke of exercise plus Recovery, a
4.6 months (range 3 to 6 placebo EMG-BFB scale for
months) 20-minute sessions judging
5 times a week for drinking from a
4 weeks glass, active
range of
motion at
wrist and EMG
surface
potentials

21
Results
 Conclusion
• Despite evidence from a small number of individual studies
to suggest that EMG-BFB plus standard physiotherapy
produces improvements in motor power, functional
recovery and gait quality when compared to standard
physiotherapy alone, combination of all the identified
studies did not find a treatment benefit.

• Overall the results are limited because the trials were

small, generally poorly designed, treatment duration varied
and utilized varying outcome measures
-2012
Objective
• To evaluate the effectiveness of EMG-BF in decreasing
wrist flexor spasticity and regaining hand function and
the ability to perform ADL during
Methodology
Populatio Intervention Comparison Outcome measures
n [SG] [CG]
40 stroke Neurodevelopmental Neurodevelopmental •Ashworth scale (AS)
patients + conventional + conventional •Brunnstrom’s
methods + verbal methods + verbal stage (BS) of recovery
encouragement to encouragement to for arm and hand
“relax” spastic wrist “relax” spastic wrist •Upper extremity
flexor muscles + 3 flexor muscles function test (UEFT)
weeks of EMG-BF Rx •Wrist and hand portion
(Five 20 min of the Fugl-Meyer scale
session/week) (FMS)
•ROM of wrist extension
•Surface EMG potentials
•Barthel Index
(BI)
Results
 Conclusion
• EMG-BF in concert with neurodevelopmental and
conventional techniques for upper extremity rehabilitation
in patients with hemiplegia due to CVA can effectively
decrease spasticity, improve motor skills and functional
use of the hand, and improve the ability to perform ADL

• EMG-BF is a valuable technique to increase the

effectiveness of the various therapeutic exercises involved
in the rehabilitation of hemiplegia
Objective
• To investigate the preliminary effectiveness of surface
electromyography (sEMG) biofeedback delivered via
interaction with a commercial computer game to
improve motor control in chronic stroke survivors
 Method
Population
• 9 persons between 40–75 years of age with moderate to severe upper
extremity motor impairment
• 6 months post-stroke

Intervention
• EMG-controlled video game system targeted the wrist muscle activation
• Participants used the system at home for 45 minutes 5 times per week for
the following 4 weeks

Outcome measures
• Primary outcome measures included duration of system use, sEMG during
home play and pre/post sEMG measures during active wrist motion.
• Secondary outcomes included kinematic analysis of movement and
functional outcomes, including the Wolf Motor Function Test and the
Chedoke Arm and Hand Activity Inventory-9
Results
Conclusion
• In this preliminary study, we found an effect at the
level of sEMG showing a decrease in co-contraction,
but no changes at the level of functional movement

• NGT may benefit from a longer intervention time and

the inclusion of more functional activity training to
assist in the transfer of changes at the muscle
activation level to changes in function
Objectives
• To determine the effect of EMG Biofeedback training of
gluteus maximus muscle on gait parameters in
incomplete SCI patients
Methods
Participants Intervention Outcomes

30 incomplete spinal EG: EMG BFB + EMG amplitude

cord injured (ISCI) Traditional Step length
patients Rehabilitation + Gait Walking velocity
Training Cadence

CG: Traditional Pre and post

Rehabilitation + Gait intervention
Training

5 sessions per week for

4 weeks
Results
Conclusion
• EMG BF when given specifically over gluteus maximus
resulted in improvement of EMG amplitude and
various gait parameters (walking velocity, cadence)
Summary
• EMG has a positive effect on muscle strength, reduces
spasticity
• Improved U.E. extremity function when given with NDT and
conventional PT
• Showed positive effects on gait parameters when given to a
specific muscle in patients with ISCI
Posturography/ Force
Platform Biofeedback
-2009
Objective
• To determine if visual or auditory force platform
feedback improves the clinical and force platform
standing balance outcomes in clients with stroke
Search strategy
• Databases searched: Cochrane Library,
MEDLINE, EMBASE, CINAHL, PEDro, CIRRIE,
REHABDATA

• Type of studies: RCTs comparing force platform with

visual feedback and/or auditory feedback to other
balance treatments

• Type of participants: Participants were stroke survivors

found to have either abnormal weight bearing in the
standing position, or standing balance impairment
during or after initial rehabilitation
• Type of intervention:
Trials that compared:
-Force platform balance training with visual or auditory
feedback and conventional Rx
-Force platform balance training with visual or auditory
feedback and another balance treatment
-Force platform balance training with visual or auditory
feedback and placebo balance treatment

• Types of outcome measures:

Primary- BBS
- TUG
Secondary- Stance symmetry
- Sway
- FIM
 Author Population Intervention/ Comparison Outcome
measures
Shumway Stroke Visual feedback on force platform and Force
-Cook rehabilitation conventional versus conventional (15 Platform:
1988 patients with minutes each therapy hour on standard COP behaviour
balance balance training or on force platform ), 2 (total sway
problems (stand times per day 2-week study area)
unassisted for 1 Stance
minute) symmetry
Mean time since (lateral
stroke 36.5 days displacement
of
sway along x-
axis)
Lee 1996 Hemiplegic Visual and auditory feedback on force WB symmetry
stroke and TBI platform with standing biofeedback
patients with trainer versus ‘conventional balance
balance trainer’ (standing training table) -
problems pulling and pushing a box with forearm
Acute stroke suspension and pelvic fixation systems
20 min, 5 days/week in both groups 55
(programs the same, but with or without
feedback) 2-4 week study
Author Population Intervention/Comparison Outcome
measures
Sackley Stroke Visual feedback on force platform and Clinical:
1997 outpatients with conventional VS placebo visual Rivermead Motor
balance feedback and conventional Assessment
problems (stand 20 min of 1 hour session with visual Nottingham 10
unassisted for feedback or placebo feedback, 3 point ADL
1minute with times/ week 4-week study with follow Force platform:
abnormal stance up at 12 weeks COP behaviour
symmetry) (sway) Measure of
mean time since stance symmetry:
stroke 136.5 (balance
days coefficient)

Wong RCT Visual and auditory feedback on force •Force platform:

1997 Standing platform with standing BFB trainer VS measure of WB
Biofeedback conventional balance trainer’ symmetry: % of
Trainer (standing training table) - pulling and postural symmetry
(dual force pushing a box with forearm
platform) suspension and pelvic fixation systems
60 min, 5 days/ week in both groups 56
3-4 week study
Author Population Intervention/Comparison Outcome
measures

Walker Stroke Visual feedback on force platform and Clinical: Berg

2000 rehabilitation conventional versus balance training and Balance Scale
inpatients with conventional, 30 minutes Timed Up and Go,
balance balance treatment with (visual feedback gait speed
problems or ’standard’ balance training added to Force platform:
(stand conventional treatment, centre of pressure
unassisted for 5 times per week behaviour, centre
1 minute) 3-8 week study with 1 month follow up of gravity
alignment (%limits
of stability) (eyes
open
and eyes closed)
Geiger Stroke Visual feedback on force platform and Clinical: Berg
2001 outpatients conventional versus conventional Balance Scale
with balance = 2 to 3 time per week, 35 minutes of Timed Up and Go
problems ’conventional treatment’ and 15 minutes
(stand Balance Master
unsupported 4-week study
57
with/without
assistive device
for 2minutes)
Author Population Intervention/Comparison Outcome
measures

Chen Ambulatory Visual feedback on force platform Force platform:

2002 stroke and conventional physical and centre of
patients occupational therapy versus pressure
conventional behaviour,
therapy (muscle strengthening, centre of gravity
therapeutic exercise and ADL alignment (%
training), 20 minutes per day, 5 limits of
times per stability) (eyes
week open
2-week study and eyes closed)
Clinical: FIM
subscale scores
for self care with
sphincter
control and
mobility with
locomotion
58
Results
Conclusion
• No clear evidence that the use of force platform
feedback improves clinical standing balance outcomes
was found
• A positive effect of force platform feedback training to
train stance symmetry, but not sway, in standing was
found
• The use of both force platform and clinical balance
outcomes in assessment may provide a more complete
picture of balance after stroke
-2014
Objectives
• To analyze the influence of posturographic platform
biofeedback training on the dynamic balance of
patients who experienced ischemic stroke
 Methods
Population Intervention Comparison Outcome
[SG] [CG] measures
21 patients Biofeedback training, Standard hospital •TUG test
with practicing maintenance treatment
ischemic of body balance (forced
stroke (11 in sway training)
the on posturographic
experimental platform for 15
and 10 in the consecutive days
control
group)
55-65 years
of age
Results
Conclusion
• Participation in biofeedback training exerted stronger
effect on the dynamic balance of patients who
experienced the stroke of the left hemisphere with
right-sided hemiparesis than in those with right
hemisphere stroke and left-sided hemiparesis
Summary
• Force-platform improves weight symmetry but not sway
• Dynamic balance improved
 AUDITORY
BIOFEEDBACK
Objective
To verify the short-term effect of the auditory feedback
prosthesis on walking in stroke patients with hemiparesis
Methods
Participants
Assessment of the effects
Outcome measures

• Gait Assessment- gait speed, stride length, step length,

maximum hip extensor angle in
stance
• Dynamic Joint Stiffness
Results
Conclusion
• Significant differences were found in the maximum
hip extensor angle and maximum ankle plantar flexor
moment with and without auditory feedback from
plantar sensations
INERTIAL BIOFEEDBACK
Objective
• To test the feasibility of using novel system (Gamepad
[GAMing Experience in PArkinson’s Disease]) in a
typical rehabilitation gym and analyze balance and
gait outcome measures comparing Gamepad-based
training versus physiotherapy without biofeedback
Methodology
Outcome measures
Primary outcome measure:
• BBS
• 10MWT

Secondary outcome measures:

• TUG
• ABC
• FOGQ
• PDQ-39
• CoP ML sway
• CoP AP sway
Results
Conclusion
• Gamepad was proven feasible for clinical use on
subjects with PD, was generally well-accepted by
patients and physiotherapists, and seemed more
effective than physiotherapy without biofeedback in
improving balance
Study limitation
• Small sample size
• Application of sensors, without biofeedback, to the
physiotherapy without biofeedback group would have
acted as a sham-device
• Technical aspects of Gamepad
 Vibrotactile
Neurofeedback
Objective
• To assess effectiveness of balance training with a
vibrotactile NFT system in improving overall stability
in PD patients
 Method
Population Intervention
10 patients Training session consisted
diagnosed of 5 repetitions of 6
with idiopathic selected training tasks
PD (each repetition lasted 20 s
or until the
movement was finished)
patient received a
vibrotactile feedback signal
during training in those
directions which showed a
higher body sway than
preset thresholds
Outcome measures
Before, during and
after the rehabilitation as well
as after 3 months
•SBDT
•Sensory Organization Test
(SOT) of Computerized
Dynamic Posturography
•Dizziness Handicap Inventory
(DHI)
•Activity-specific balance
confidence scale
•Recording the number of falls
over the past three
months
Conclusion
• Results showed that a free-field vibrotactile NFT with
Vertiguard1-RT device can improve balance in PD
patients in everyday life conditions very effectively,
which might led in turn to a reduction of falls
MIXED
-2011
Question
• Is biofeedback during the practice of lower limb
activities after stroke effective in improving
performance of those activities, and are any benefits
maintained after intervention ceases?
Search strategy
• Databases searched: Cochrane Library,
MEDLINE, EMBASE, CINAHL, PEdro
Method
Results
Conclusion
• Augmenting feedback through the use of biofeedback
is superior to usual therapy/placebo at improving
lower limb activities in people following stroke
• Furthermore, these benefits are maintained in the
longer term
Objective
• To compare therapeutic effects of an
electromyography (EMG) biofeedback augmented by
virtual reality (VR) and EMG biofeedback alone on the
triceps and biceps muscle activity imbalance and
elbow joint movement coordination during a reaching
motor task in normal children and children with
spastic cerebral palsy
 POPULATION INTERVENTION COMPARISON OUTCOME

18 children: 10 CP 1 session of EMG EMG feedback •Elbow extension

(4 Diplegics, 1 feedback (30 alone ROM
Hemiplegic, 5 minutes), •Biceps and Triceps
Quadriplegics) and followed by 1 muscle strength
8 Normal children session of the •Box and block test
AGE: 7-15 years old EMG-VR feedback •EMG and 3-axis
male and females (30 minutes) after accelerometer (3-D
a 1-week washout movement
period coordination)
Results
CONCLUSION
• Superior benefits of EMG biofeedback seen when
augmented by virtual reality exercise games in
children with spastic CP

• The augmented EMG and VR feedback produced

better neuromuscular balance control in the elbow
joint than the EMG biofeedback alone
 Summary
Intervention Strengths Limitations

EMG •Reduces co-contraction and Inconclusive for L.L.

improves selective muscle activity function
•Showed good results in U..L. improvement
function when given with
conventional therapy
Posturography Improves weight symmetry and Did not show
dynamic balance improvement in sway
Auditory Showed a significant improvement
in walking
Inertial (GAMEPAD) Proven feasible for clinical use on
subjects with PD
Vibrotactile Can improve balance in PD and
reduce number of falls
Augmented Augmenting feedback through the
use of biofeedback is superior to
usual therapy/placebo
THANK YOU