Treatment Guide Myo 200 Drs. V. SMEETS Prof. Dr. E. DI PALMA ®

Treatment Guide Myo 200
®
Drs. V. SMEETS
Prof. Dr. E. DI PALMA
®
for total support
Copyright GymnaUniphy NV, 2008
GymnaUniphy NV
Pasweg 6A, 3740 Bilzen, Belgium
Phone +32 (0)89 510 510 • Fax +32 (0)89 510 511
www.gymna-uniphy.com • e-mail: info@gymna-uniphy.com
Content
General information 1.
Biofeedback 1.1
Introduction
1.2
What is biofeedback?
1.3
Goal of Biofeedback Therapy?
1.4
What is electromyography (EMG)?
1.5
Three stages of biofeedback training
1.6
Biofeedback and muscle strengthening
2.
Urinary incontinence 2.1
Introduction
2.2
Types of incontinence
2.3
Prevalence of urinary incontinence
2.4
Risk factors for developing urinary incontinence
2.5
How does the urinary sytem works?
2.6
Methods for pelvic muscle strengthening
2.7
Advantages of pelvic floor physiothrapy
6
6
6
6
6
7
8
8
Principles EMG
1.
General information
2.
Basic principles
16
16
17
Practical Applications
Unstable shoulder
Pattelofemoral Pain Syndrome
Recovery of the Post Operative Knee (QF-muscle)
Chronic Tension Headache
Repetitive Strain Injury
Biofeedback for Pelvic Training
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18
24
29
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36
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10
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Unique software features
1.
Fatiguability index
2.
Intake and voiding diary
3.
General assessments
4.
Reporting function
5.
Create your own templates
6.
3D animation software for children
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Overview probes
60
References
62
Notes 66
General information
1. Biofeedback
1.1
•
•
•
Introduction
‘Bio’ is the Greek prefix meaning `life’.
Feedback is a term for receiving information on current behavior.
A ‘Biofeedback is used to influence or modify future behavior.
Biofeedback is the process in which a client is given information about
specific body events through the use of instrumentation.
1.2
What is biofeedback?
Biofeedback is a type of treatment where people are trained to improve their
health by using signals from their own bodies. Biofeedback is a group of therapeutic procedures that utilizes electronic or mechanical instruments to accurately
measure, process, and provide ‘feedback’ to persons information about neuromuscular and or other body activity.
Biofeedback has been used successfully to treat muscle dysfunction and is also
often used in behavioral therapy for the treatment of urinary incontinence (UI).
1.3
Goal of biofeedback therapy?
The goal of biofeedback therapy in the treatment muscle re-education is to modify
a person’s behavior and train in methods to regain muscle control. Persons are
taught to alter physiologic responses of the muscles that are involved during a
certain movement. Biofeedback therapy is a vital component of any behavioral
program which deals with restoration of muscle re-education.
1.4
What is electromyography (EMG)?
Measuring the action potentials in muscles is known as Electromyography (EMG).
Myofeedback is a derivative form of the observation of the EMG signal and can as
a functional diagnostic tool as well in evaluation and therapy.
Myofeedback provides extra information for the motor learning process. It enables
the patient to improve the muscle function through increasing muscle awareness.
Myofeedback provides extra feedback when the natural feedback signals of the
patient are (in)sufficient to achieve the contraction. It is especially useful in the
case of muscular activity that produces a contraction or movement that is invisible to the patient.
Electromyography is defined as: the process of recording and displaying
graphic tracings of the voltage levels in muscle tissue, used in the diagnosis
and treatment of muscle and nerve disorders.
1.5
Three stages of biofeedback training.
Biofeedback helps individuals bring their physiological activity into a proper range
of functioning but it also helps to convince individuals that it is in fact possible
to control events that bear on their capacity to cope with stressful circumstances.
To further understand the biofeedback process, Lehrer and Woolfolk (1993) have
identified three stages of BFT.
1. Acquiring awareness of the maladaptive response.
2. Learning to control the response. Using signals from the biofeedback equipment to control physical responses: The individual is assisted in reaching
certain goals related to managing a specific physical response.
3. Learning to transfer the control into everyday life. Transferring control from
biofeedback equipment or the health care professional: Individuals learn to
identify triggers that alert them to implement their new-found self-regulation
skills into everyday life.
1.6
Biofeedback and muscle strengthening.
EMG biofeedback has been shown to produce more rapid and significantly greater
development of strength when combined with more traditional form of physical therapy. EMG biofeedback has been successfully used for muscle reeducation
and muscle strengthening in hemiplegic patients, rehabilitation following surgery
or trauma, selective training of the vastus medialis during patella realignment.
Closed chained, or muti-joint exercises have been recognized to offer many advantages over open chain, or single joint exercises for both physical therapy and
strength development.
The use of EMG biofeedback during muscle strengthening exercises significantly improves the rate of functional recovery of the muscle. Visual (bio)feedback
establishes positive motivational effects for the patient; it is an important
source of motivation. When individuals are more are more keenly aware of their
performance level, they are more impelled to set and strive for performance goals
(Draper, 1990).
2. Urinary incontinence
2.1
Introduction.
Urinary incontinence (UI) is a significant common health problem in modern society. All over the world, UI affects more than 50 million people, and women in
particular. While rare life-threatening, incontinence may seriously influence the
physical, psychological and social wellbeing of the affected individuals.
Definition of incontinence:
The International Continence Society (ICS) has standardized terminology in lower
urinary tract function: UI is defined as “the complaint of any involuntary urinary
leakage”.
2.2
Types of incontinence.
Type
Definition
Mechanism
Disorders
Urge
Inability to delay
once the urge
occurs
Detrusor hyperactivity
Idiopathic (commonly in the elderly)
Genitourinary conditions (cystitis,
stones)
Stress
Loss of urine
with increased
abdominal
pressure
Sphincter
failure
Weak or injured pelvic muscles
Sphincter weakness
Overflow
Partial retention
of urine behind
an obstruction
Outlet obstruction. Loss of
innervation
Obstruction (prostate, cystocele).
Naturopathic (diabetes, nerve injury)
Functional Inability to get in Physical or cog- Dementia or delirium
the toilet in time
Mixed
10
Any combination
of the above
nitive impairment
Physical limitations (lack of mobility).
Psychological or behavioral causes
2.3
Prevalence of urinary incontinence.
Prevalence (%)
Urinary incontinence is an embarrassing problem to many women and thus its
presence may be significantly underreported. Women experience UI twice as often as men. Several studies have shown that the prevalence of any UI tends to
increase up to middle age, than plateaus or falls between 50 and 70 years, with a
steady increase with more advanced age. Figure 1 shows that slight to moderate
UI is more common in younger women, while moderate and severe UI affects the
elderly more often.
Severe
Moderate
Slight
Unknown
Age group (years)
Prevalence of incontinence by age group and severity (Figure 1)
11
Stress urinary incontinence (SUI) is the most common form of urinary incontinence in females aged 16-60 years. Figure 2 shows the trends in prevalence of UI
at different ages. In women aged 60 years and above, urge and mixed incontinence are increased.
Prevalence (%)
Unknown
Mixed
Urge
Stress
Age group (years)
Prevalence of UI types by age group (Figure 2)
12
2.4
Risk factors for developing urinary incontinence.
In addition to the effect of age, scientific studies suggest other risk factors for UI.
These include pregnancy, parity, obstetric factors, lower urinary tract symptoms,
women with a higher body mass index (BMI), menopause, experience of continence problems in childhood, family history, genetics etc.
2.5
How does the urinary sytem works?
Incontinence occurs because of problems with the pelvic floor muscles and nerves
that help to hold or release urine. The body stores urine - water and wastes removed by the kidneys - in the bladder, a balloon-like organ. The bladder connects
to the urethra, the tube through which urine leaves the body.
Front view of bladder and sphincter muscles (Figure 3)
13
During urination, muscles in the wall of the bladder contract, forcing urine out
of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will
occur if your bladder muscles suddenly contract or the sphincter muscles are not
strong enough to hold back urine. Urine may escape with less pressure than usual
if the muscles are damaged or weakened, causing a change in the position of
the bladder.
2.6
•
•
•
•
14
Methods for pelvic muscle strengthening.
Contraction exercises. The goal of contraction exercises is to increase the
tone and strength of the pelvic floor muscles.
Vaginal cones. The use of vaginal cones is also aimed at strengthening the
pelvic floor muscles. As the pelvic floor muscles (levator ani) become stronger
the patient uses heavier cones.
Biofeedback. A signal that makes the individual aware of physiologic changes
in response to a voluntary action. The simplest biofeedback technique is a
statement about the strength of the patient’s contraction of the pelvic floor
muscles.
Electrical stimulation. The current causes an involuntary contraction of the
pelvic floor muscles, allowing retraining and strengthening of the structures.
2.7
•
•
•
Advantages of pelvic floor physiotherapy.
Prevention: Women of all ages need to have strong pelvic floor muscles.
Healthy, fit muscles pre-natally will recover more readily after the birth.
Reduced indication for incontinence surgery: Pelvic floor muscle training will
lead to a reduced indication for incontinence surgery.
Economic cost benefits, first line physiotherapy: From a health economics
perspective, research evidence emphasize that physiotherapy should be routinely implemented as first line treatment before consideration of a surgery
(Neumann et al, 2005).
15
Principles EMG
1.
General information
EMG is similar to a voltmeter device. It measures the summation of passage of
multiple units of action potentials (m.u.a.p) between two points on a muscle belly
from the vantage point of the skin surface. It can also measure the frequency of
passage of the m.u.a.p.s. The summation of the action potential passage shows
up as an amplitude form, i.e. the greater the number of passing action potentials,
the higher the amplitude of the micro-voltage.
The electrical muscular activity in a normal muscle will include three parameters:
1. A resting value, which is generally less than 4mV (rms) and can decrease to
1mV or even less, in some conditions. The resting value should be the same,
before, and after a muscular contraction through a range of motion.
2. A maximal activity value, which may change according to gravity and resistance over a period of time. This maximal activity can be achieved through
reliable muscular contractions, repeated a number of times and interspersed
with adequate periods of rest.
3. A median frequency of passage of volleys of m.a.u.p.s. in the course of time.
This frequency shows a decrease of amplitude as a function of time. In a
number of muscles this has been shown to be representative of the subjective
perception of fatigue.
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2.
Basic principles
Electrode placement:
• Electrode placement needs to follow clear anatomic patterns and be at a fixed
distance on the same muscles.
• The most consensually accepted distance is 2 cm between the active electrodes.
• The ground electrode may be placed further away however the ground should
be equidistant from both active electrodes.
Testing:
At least 5 repetitions of motion through the R.O.M. are needed in order to establish the repeatability and validity of the compliance of the person tested for the
requirements of the testing.
Testing can be done in three different modalities with regards to gravity and
resistance:
1. The first modality is that of the muscle motion through the R.O.M. without
any resistance or conscious effort.
2. The second modality is that of the muscle motion through the R.O.M. while
the person exerts maximal voluntary contraction.
3. The third modality involves a set resistance against the muscle’s motion
through the R.O.M. (note, a variant of this modality involves an isometric
contraction, i.e. with a set resistance so large that the muscle contracts
without being able to move the joint in space).
17
Unstable shoulder
Introduction
Anterior shoulder instability and impingement are common (athletic) complaints
associated with overuse, joint laxity, post-traumatic dislocation and muscle imbalance. While traditionally treated as clinically discrete entities, it is accepted
that considerable overlap exists between functional instability and anterior impingement (Garth, Allman, Armstrong, 1987; Reid et al, 1987).
The biofeedback program utilizes targeted muscle feedback to perfect motor skills.
By electronically monitoring and amplifying activity of the external rotators during an apprehensive motion with immediate visual and/ or auditory feedback
to the subject, the performance is changed or shaped. This program emphasizes
muscle control rather than strength, requires motivation, training and routines to
maintain and control the shoulder stability.
Electrode placement
•
Attach the sensor below the scapular spine with the 2 active electrodes to the
orientation of the muscle fibers like picture 1.
Biofeedback treatment program
1. To determine threshold and gain settings; instruct the patient to flex the
shoulder forward to +/- 70 degrees. The Myo 200 will automatically adjust the
“capture target”.
Start practicing: Instruct the patient to flex the shoulder forward to +/- 70
degrees to increase EMG activity as well above the target value. (sets of 10
repetitions).
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Picture 1
19
2. Ensure that the shoulder is in a pain-free neutral position. Instruct the patient
to use the visual/audio biofeedback to increase EMG activity as well above the
target value. Instruct the patient to tight the rotator cuff muscles in the neutral
position in order to glide and hold the humeral head posteriorly (see picture 2).
> This is a key component and must successfully be performed about 100 times
(10 series of 10) prior to progressing to active movement. The use of
many repetitions builds endurance. This procedure is quite fatiguing; it
may require several sessions before the patient can progress to next step.
3. With the threshold set at twice the value achieved in Step 1, place the
patient’s elbow in flexion. Instruct to forward flex the adducted and neutral
rotated shoulder to 90-100 degrees. As the shoulder is flexed between 70 and
90 degrees, have the patient tighten the rotator cuff and achieve the threshold setting, trying to increase the EMG activity above the target value.
> If pain or a sense of subluxation is experienced, stop, rest and start
again through a smaller arc of movement and/or with reduced threshold settings. When the patient can successfully perform 100 consecutive repetitions, progress by increasing the threshold and/or movement as shown in
image 3.
4. Movement progression:
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As the patient masters each level, progress through the following exercises:
a) Forward flexion with a straight elbow.
b) Forward flexion with increasing external rotation.
c) Abduction with flexion progressing to elbow extension
d) Abduction with elbow extension with increasing external rotation.
e) Abduction from flexion.
f) Abduction from flexion with increasing external rotation (see picture 3).
g) Reach for objects behind back or overhead.
Picture 2
Picture 3
21
5. When the above progression of increasingly difficult tasks has been completed, progress to the activities specific to the sport or work task that caused
the difficulty. Break the movement down into component parts and introduce
catching or throwing activities in preparation for a gradual return to normal
activity (pictures 4 and 5).
Other exercises
If general weakness exists, instruct the patient in appropriate progressive resistance exercises. Include push-ups for serratus anterior (with the arms abducted)
and external rotation exercises resisted using surgical tubing.
Avoid resisted exercises which load in an impingement position. All pain free
activities are allowed and encouraged.
Figure Instability and impingement are related
Conclusion
This program emphasizes muscle control. Strength acquisition is important, but
secondary. Electrode placement is critical. The biofeedback program is physically
and mentally demanding, therefore, appropriate rest periods and encouragement
must be provided. Slow and careful progression is usually necessary. Commitment
by the therapist and client are required for the program’s success.
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Picture 4
Picture 5
23
Pattelofemoral Pain Syndrome
Introduction
Patellofemoral pain is a common ailment affecting one in four of the general
population(McConnel, 1986). It is caused by a variety of factors including abnormal lower limb mechanics, Vastus Medialis Obliquus (VMO) insufficiency, tight
lateral structures and tight anterior and posterior muscles. The condition often
develops gradually and is characterized by a diffuse ache in the area of the anterior knee.
Causes of PFS
•
•
•
•
•
Muscle imbalance between medial and lateral quadriceps (weak VMO- medial
quadriceps).
Poor patella alignment (hypermobile, lateral glide).
Decreased hamstring, ITB, hip flexor and calf flexibility.
Over-pronation (wrong shoe wear).
Over training.
The management of patellofemoral pain involves: first, a thorough analysis of
the problem to identify the contributory factors; and second, correcting these
problems. Lower limb mechanics are assessed and the alignment of the patella
is evaluated. Patellar alignment is improved with tape and muscles are trained
to optimize dynamic control. Taping the patella into correct alignment has been
shown to increase EMG activity of the VMO, increase muscle torque and decrease
pain. Change in the muscle activity of the knee improves patellar tracking and
lower limb mechanics and significantly decreases pain.
In many instances, the problem is related to the timing of muscle contractions,
when there is an imbalance of muscle activity, lateral tracking of the patella will
result. Training requires subtle shifts in the timing of the activity of the VMO: VL
(Vastus Lateralis) muscles.
24
Figure 5
25
Electrode placement
•
•
The patient sits in a chair with the foot on the floor and leg relaxed.
The electrodes are placed over the VMO with the 2 active electrodes parallel to
the orientation of the muscle fibers (you can choose between single or dual
channel).
Only MO activation
Comparison VMO to VL activity
Single Channel EMG
Dual Channel EMG
Single Channel: see picture 6
Dual Channel see picture 7
Biofeedback treatment program
EMG monitoring is utilized to assist with the assessment of muscle activity and
to demonstrate any imbalance to the patient. Training may also be specific to a
particular part of the range of motion i.e. at 20-30 degrees of knee flexion, as the
patella is engaging in the trochlear groove of the femur. See picture 6
As the VMO control improves, training progresses to include functional activities
such as: training prorioception, climbing stairs, squats, vocational and sporting
activities, provided they are pain free. See picture 8
26
Picture 6
Picture 7
Picture 8
27
A good rehab program should consist of biofeedback in combination with
flexibility and mobility exercises, strengthening exercises, especially for the hips
and core, and balancing exercises. The use of a knee brace may be necessary
depending on the structural alignments present.
Benefits of biofeedback treatment in PFS:
•
•
•
•
With EMG it becomes easy for the patient to change the timing or the quantity
of VMO activity to VL activity.
The patient can progress to monitor his/her effort in functional or sporting
activities.
Motivating patients is easier when they understand the underlying mechanism contributing to their problem.
Skill is enhanced and maintained with practice.
Conclusion
Clinical evidence shows that the VM and VL muscles can be trained specifically
to align the patella. Ongoing and regular training will produce effects that are
beneficial and long term, and the patient can remain free of pain even while participating in activities which are demanding on the patellofemoral joint. Using a
single or dual channel EMG device to monitor the VMO and evaluate the patient’s
progress is the key to success.
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Recovery of the Post Operative Knee
(QF-muscle)
Introduction
Following an anterior cruciate ligament (ACL) reconstruction, immobilization and/
or disuse of the operative limb can result in significant quadriceps femoris (QF)
muscle atrophy and weakness, even within the first few days following surgery and
certainly the first few weeks1. Rehabilitative exercises during the early phases of
treatment typically include QF muscle setting (QS) and straight leg raises (SLR).
The recovery first requires that the patient recover voluntary control of the muscle
so that strengthening exercises can be performed effectively.
The biofeedback is used to reeducate the patient in voluntary contractions of the
QF, providing the patient with immediate information regarding the correctness of
their efforts during QS’s and SLR’s. Patients may begin working with biofeedback
as soon as possible after surgery. Typically, patients are asked to perform QS’s and
SLR’s within a day of surgery and they can easily begin the biofeedback monitoring at this time.
Electrode placement
•
With the leg in extension place the electrode 3-5 cm above the superior
border of the patella and 2-3 cm medially (figure 6).
•
Make sure to have the positive and negative electrodes parallel to the muscle
fibers. The incision pattern will determine the actual location but the goal is
to focus on extensor mechanism activity during QS’s and SLR’s.
Electrode
placement
+ Positive
- Negative
Reference
Figure 6
29
Biofeedback treatment program
1. Use the biofeedback with the QS exercise: with the patient sitting up, affected leg straight out on the table. The patient should be able to perform 3 sets of 10 QS’s to the satisfaction of the therapist before moving
on to the next phase of the program in order to avoid improper technique.
2. By readjusting the settings (capture target), the difficulty of an exercise may be increased or decreased, according to the needs of the patient.
It
is
important
to
stress,
however,
that
the
importance lies in the quality of contraction versus the quantity.
With the QF set, the patient lifts leg
approx. 30 cm off the floor or table.
Figure 7
3. Start with Straight Leg Raises (figure 7).
in a supine position, leg extended. The
ceps femoris first and then lifts the leg
inches) off the floor or table and holds
30
This exercise is performed
patient sets the Quadriapproximately 30 cm (12
for a 5 second count .
4. By monitoring the Myo 200 during each SLR, the Quadriceps femoris should
remain set with no evidence of extensor lag during the hold. Monitoring this
exercise with the biofeedback makes the patient more aware of changes
in the QF motor unit activity during the hold time and better able
to maintain a constant and complete contraction throughout the exercise
repetition.
Conclusion
In our experience, Biofeedback is most useful during the first 2-4 weeks following ACL reconstruction. We suggest that it will be used with QS’s (3 sets of 10
repetitions, 3 times per day) and SLR’S (3 sets of 10 repetitions 3 times per day;
progressively adding 2-10 lbs of ankle weight, as tolerated). Thresholds should
be set so that the patient has to exert maximally to achieve the goal. Patients
should be encouraged to increase these thresholds as soon and as regularly as
possible, otherwise the biofeedback becomes only a monitoring device and not a
training tool.
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Chronic Tension Headache
Introduction
Headache is the most common pain complaint (Schwartz, 1987) and the most
frequent medical problem seen in medical clinics. Most experts (Andrasik, Blanchard, 1987) believe that the majority of headaches are muscle tension-type.
Community-based epidemiological studies have found that 14% of men and 29%
of women have had headaches either every few days or headaches which significantly bothered them (Dupuy et al, 1977).
Tension headache is generally described as a bilateral dull ache, pressure or caplike pain that is usually located in the forehead, neck and shoulder regions. The
headache typically occurs from two to seven days a week and can last from one
hour to all day; a small proportion of tension headache sufferers have continuous
headache.
Electrode placement
•
•
Place the two active sensors approximately in the center of the forehead in
line with the pupil of the respective eye. The reference (ground) sensor is
placed between the two active sensors. See picture 9.
We recommend the use of disposable EMG sensors to insure against infection
Biofeedback treatment program
1. A reading of less than 2 microvolts generally indicates a fairly relaxed muscle
group. If the level starts off and remains low even during stress provoking imagery or discussion, or after the patient has gone through an adequate course
of forehead EMG biofeedback and little change in headache activity is noted,
2. advance to the shoulder and neck regions (picure 10). Palpation for muscular
tenderness may also be used in the selection of electrode placement sights.
32
Picture 9
Picture 10
33
3. Give the patient a number of possible strategies to choose from.
We customarily describe 6 possible biofeedback strategies:
RELAXATION STRATEGIES
• Relaxing imagery, in which the patient imagines a pleasant scene.
• Relaxing (autogenic) phrases repeated over and over again. We
have found that the effective phrases with biofeedback training
are those the patients think up on their own.
• Deep breathing procedure, during which the patient with eyes
closed concentrates on relaxed, slow and moderately deep diaphragmatic breathing and repeats a relaxing word such as “relax”
or “peaceful” while relaxing.
• Becoming aware of sensations of tightness and tension in the forehead, by focusing on what it is like when those muscles relax,
loosen up and unwind.
• Nothingness. Some patients report that if they can make their
minds blank and think of nothing – actually stop thinking – they
can relax and lower their muscle tension.
• Mental games. Some patients find that focusing in on a color
(“warm” colors, such as blue, green or brown seem to work best)
or actually play a game in their mind, such as tic-tac-toe, bowling,
cards or basketball, are effective in lowering their muscle tension
levels.
4. In the first session, we usually tell the patient to pick only one strategy
and stick with it the entire session. We keep the initial session short - a 3-5
min. adaptation period (Just sit quietly with your eyes closed) and a maximum of 12 min. of biofeedback.
5. In latter sessions, we increase the biofeedback portion to a maximum of 25
min. Emphasize that learning to relax muscles at will can be a difficult response to learn and that it may take some time before they can lower their
forehead muscle tension reliably; we tell them not to get discouraged if they
cannot control their EMG levels immediately.
34
6. Instruct the patients to let the response occur rather than make it
occur, to be passive rather than try to force their forehead muscles to relax.
7. At the end of the biofeedback session when the sensors are removed and the
sessions data is saved, inquire as to which strategy was employed and the
patients perception as to how effective it was and review the actual report by
printout of the data with the patient. Throughout this review we attempt to
impart to the patient the most positive feeling of success gained, based on
the realities of the sessions data.
Homework
Home practice has traditionally been considered an essential aspect of all interventions for chronic tension headache (Schwartz, 1987). Home practice can be
conducted in many ways: The simplest form of homework is to instruct the patient
to practice the office strategy that seemed to work the best at home and in other
real world locations such as the job, supermarket, etc. (we usually instruct them
to do so at least four times a day).
35
Repetitive Strain Injury
Introduction
Some workers develop chronic neck and upper limb pain also known as repetitive
strain injury. (RSI), cumulative trauma disorder (CTD) or overuse syndrome, from
long hours of repetitive tasks at personal computer workstations.
Computer users can learn preventive skills to sense muscle tension and incorporate relaxation and regeneration of muscles during data entry and mouse use.
Biofeedback instruments can be used to monitor specific muscle sites and to warn
the user of excessive strain or overuse habits that can lead to chronic pain or
injury. This mastery process reduces the risk of RSI.
Electrode placement
•
36
The minimum requirement for the assessment is two channels of surface
electromyography (sEMG).
Figure 8
37
Two channel sEMG sensor placement
A) Forearm sEMG: Place the active electrodes midpoint on the extensor and flexor
muscles (see picture 11) to monitor forearm tension. The purpose for monitoring
the forearm is that most subjects do not relax the fingers or wrist muscles as long
as the fingers are on the keyboard or holding the mouse.
B) Neck and shoulders sEMG: Place one active electrode over the left scalene and
the other, midpoint on the right trapezius (see picture 13 and 14). The purpose
of monitoring the neck and shoulders is that most subjects raise their shoulders
and tend toward thoracic breathing patterns during task performance. The left
scalene to right trapezius placement will also monitor bracing by the scalene and
sternocleidomastoid muscles.
Four channel sEMG sensor placement
Sensors are placed to allow bilateral analysis during the symmetry assessment. The
most common bilateral electrode placements (right and left) include the following
muscles: upper trapezius, lower trapezius, sternocleidomastoid, rhomboid, and
pectoralis. The purpose for monitoring upper and lower trapezius is to enhance
scapular stabilization since the lower trapezius will inhibit the upper trapezius
activity (see picture 12). (For exact electrode locations see: Soderberg, 1992:
This manual is free and available from NIOSH, see recommended sources for more
information; and Basmajian & Blumenstein, 1980).
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Picture 11
Picture 12
Picture 13
Picture 14
39
Training and Education
The training protocol consists of reducing the observed risk patterns and generalizing these new skills into the persons work behavior. If significant dysponesis is
observed, a more detailed sEMG analysis of specific muscles is required. The more
specific the feedback, the more successful will be the skill acquisition.
•
•
•
•
Encourage lowering of arousal during task performance and breaks.
Teach diaphragmatic breathing to reduce hyperventilation (Peper, 1990).
Teach momentary regenerative breaks during continued task performance.
Sustained muscle activity of greater than 30 seconds needs to have regenerative epochs (1-2 seconds) of low EMG activity. The micro-breaks are much
more important than the muscle tension during the task (Taylor, 1993).
Develop muscle strength, flexibility and bilateral symmetry appropriate for
task performance through movement exercise and workstation rearrangement
(Wilson, 1994).
Training and goals
A. OPTIMIZE ERGONOMIC CORRECT POSITION
Optimize body position at the work station with sEMG monitoring. For example,
place sensors on deltoid or trapezius to identify the neutral arm position while
hands are on keyboard (Peper and Shumay, 1994).
B. EMG GOALS
1. Inhibit scalene/trapezius sEMG activity while fingers are on the keyboard
during rest and data entry. This means the person learns to sense bracing in
the shoulders and lets the shoulders stay relaxed during data entry.
2. Inhibit finger/wrist flexor/extensor sEMG activity when fingers are resting on
keyboard.
40
3. Inhibit shoulder girdle and arm bracing (excessive sEMG activity) while using
a mouse.
4. Inhibit sEMG co-contraction of muscles such as SCM.
5. Teach scapular stabilization utilizing lower trapezius and serratus anterior
sEMG feedback to inhibit upper trapezius activity (Bender, 1993).
6. Monitor sEMG and inhibit dysponetic activity from relevant muscle groups
while performing job related keyboard entry tasks.
C. RELAXATION/STRENGTHENING PRACTICES
1. Head rotations: SLOWLY look over right shoulder. Hold 20 seconds, back to
center. Repeat on the other side. (Minimize shoulder movement as much as
possible.)
2. Side headbends: Put right ear to right shoulder. Hold 20 seconds, back to
center. Repeat on other side (minimize shoulder movement as much as possible).
3. Turkey pull: GENTLY pull your neck backwards as if someone had a string attached to the back of your neck and was pulling it backward. Keep the jaw
parallel to the ground and shoulders relaxed. Do 2-30 times daily.
4. Shrug shoulders backward and forward in a circular motion, go slowly. Several
circles should be executed-- each of a different diameter.
5. Place arms at sides as if you were standing at attention. Keeping arms as
straight as possible, raise them up over your head until the backs of your
hands meet above your head. Ensure that palms face down as arms extend.
The action should look like a slow motion jumping jack (or a very lethargic
duck trying to fly). Do not arch lower back.
6. Do Dynamic Relaxation of the neck, shoulders, arms, wrists, hands, and fingers (Peper and Holt, 1993). Teach internal mastery of high and low muscle
tension and the ability to relax the muscle at will.
7. Take brief 1 to 2 seconds regenerative breaks every 30 seconds during keyboard data entry and mouse use. For example, drop hands to the desk top
or lap, the sEMG of the neck and shoulders should instantly return to low
baseline levels.
41
D. EMOTIONAL CONTROL
1. Enhance awareness of how negative emotions contribute to dysfunctional
patterns.
2. Develop communication and problem solving skills to resolve work and/or
family conflicts.
3. Teach thought stopping and/or task focusing exercises.
E. IMPLEMENTATION
1. Generalize the above learned skills while performing relevant keyboard entry
tasks at the actual job site.
2. Breathe diaphragmatically and decrease breathing rate during relevant task
performance.
42
Biofeedback for Pelvic Training
Introduction
The core behavioral treatment of urinary incontinence is pelvic muscle re-education. The pelvic floor refers to the complex of connective tissues and muscles
that close off the pelvic outlet and act as a “floor” to the abdominopelvic cavity.
The primary muscular component of the pelvic floor is the Levator Ani group of
striated muscle fibers which is comprised of the pubococcygeus, puborectalis and
the ileococcygeus muscles. The external sphincter of the urethra and the anal
sphincter are in continuity with these muscles. Both receive pudendal innervation. Biofeedback “takes the guesswork out of pelvic muscle training” because it
enables the patient to improve pelvic muscle function through muscle awareness,
which, when combined with a home exercise program, leads to increased muscle
strength and improved coordination.
Probes
Because of past concerns about sterilization of the probes, “Single-User” probes,
have become the standard. Before insertable EMG vaginal and anal probes became
widely available surface patch electrodes were placed near the anus to record
muscle activity. However, the insertable sensor’s electrodes lie much closer to
both superficial and deeper segments of the pelvic floor muscles allowing for more
sensitivity to the muscle activity
Intake and voiding diary
A daily bladder or bowel diary should be kept for one week prior to beginning a behavioral program. During the pre-treatment visit, the healthcare professional will
provide educational information and explain the use of the equipment, including
the sensor and its placement.
43
A suggested assessment protocol follows:
•
•
•
•
•
44
The patient is lying at the treatment couch or seated on a firm chair. This
position increases the patient’s proprioception of the target muscles due to
contact with the firm surface.
The probe or patch electrodes are then connected to the EMG instrumentation. (For EMG: always use the reference electrode).
These surface patch electrodes can be placed above the pubic symphysis and
to the right of the umbilicus, 3-4 centimeters apart, to monitor muscle activity. After connecting to the EMG instrument, the assessment can begin.
First, baseline information is gathered for the resting EMG levels of the pelvic
floor muscles. The resting EMG levels should be acquired over a 1-3 minute
interval.
Typically, a resting EMG reading under 2 microvolts rms is considered to be
within normal limits, however, many patients will exhibit higher resting tones
during the initial biofeedback visit and, occasionally, during the first few
minutes of subsequent sessions.
Always start to determine the capture target at the Myo 200. If the capture
target is set, ask the patient to tighten the pelvic muscles and to hold the
contraction (for 10 seconds). After the pelvic muscle contraction, a period of
rest should follow, typically to 10 seconds.
> > It is important that the pelvic muscles are isolated and that the accessory muscles of the legs, abdomen and buttocks are not contracted.
•
•
•
•
A second channel of EMG is necessary to rule out undesirable and often subtle
activity from the accessory muscle groups.
Instruct the patient to contract and relax the pelvic muscles 4 to 6 times,
allowing for 10 seconds rest periods between each contraction. These voluntary contractions should be observed for maximal amplitude, average amplitude and fatigue.
A series of five rapid, forceful contractions, sometimes called “quick flicks”,
are a good measure of the fast twitch fibers of the pelvic floor. The ability to perform 5 such rapid contractions in a ten second period is a goal in
training patients to be able to use their muscles in a functional manner such
as “squeezing” while coughing or sneezing. (See figure 9).
During every treatment session, the data can be saved, viewed on the screen
and printed out for a doctor report.
Biofeedback treatment program
Methods for training the pelvic floor musculature
Using a dual channel instrument, such as the Myo 200 permits one to isolate only
the pelvic muscles. This is mandatory for further muscle training to continue. One
channel monitors the abdominal muscles and the other, the pelvic muscles.
•
•
Muscle strengthening is done with maximal contractions, that are held for
5-10 seconds at a time, depending on the patient’s ability, with 10-second
rest periods in between. These work/rest cycles are repeated several times,
until the contraction begins to show fatigue, or when the patient begins to
compensate with accessory musculature. (see figure 9).
Endurance training is done with submaximal contractions held for
increasingly longer periods of time. (See figure 9).
45
•
•
For a detailed view, use the unique fatigability index.
Speed of recruitment is practiced with several rapid forceful contractions
(flicks) in a short time frame, for example, 5 successive contractions, performed
within ten seconds (Figure 9). A progressive contraction can also be done,
asking the patient to contract and relax gradually.
Figure 9
The total time committed to actual biofeedback in a 45 minute appointment is
approximately 15 minutes. The time spent on each type of training depends on
the patient’s problem and response. The remainder of the time is spent on patient
education, review of voiding diary, and instruction in voiding schedules and dietary and fluid modification, as appropriate to each patient. A typical EMG signal
for a similar protocol is displayed in figure 9).
Home exercises
A review of the record keeping data, combined with a biofeedback session in the office or clinic, is usually suggested every 7-10 days. Initially, the patient is asked to practice at home, every day, with an exercise prescription based on her/his assessment in the initial session.
For example, if the patient was only able to sustain a 4 second contraction during
the first visit, it would be appropriate to prescribe home exercises in the following
manner:
46
•
•
•
•
Contract for a count of 4, relax for a count of 10 for 5 repetitions. Repeat the
preceding 5 times a day. The duration of the contractions should be increased
until the patient is able to sustain for a full 10 seconds. As the patient
progresses, or, initially, if appropriate, two or three EMG feedback sessions
can be prescribed using a home unit.
Additional non-instrumented muscle contraction exercises are also given,
based on the patient’s performance within the clinical setting. These can be
tailored to suit the patient’s individual lifestyle, taking into consideration
that busy schedules may hamper compliance.
The literature shows that 30 to 80 contractions, daily, are sufficient to improve pelvic muscle function thus reducing incontinent episodes. There are a
variety of other suggestions available in the literature.
A workable schedule, for many patients, has been 5 or more sets of 5 repetitions
throughout the day. A commitment of 1,5-2 minutes for exercise, several times a
day, is agreeable to most patients without disturbing their routine to the point of
non-compliance. During subsequent weeks, these exercises should be practiced
with increasing duration and effort, with changes in position during exercise.
Once the biofeedback training sessions are complete and symptoms have resolved,
it is imperative that the patient continue muscle contraction exercises to maintain the effective muscle function and symptom resolution.
Conclusion
Incontinence is an extremely prevalent disorder. Biofeedback has had a great
impact upon incontinence, due to its ease of use, low cost and very high success rate. Most patients can use EMG biofeedback successfully at home. Although
treatment time varies, in most people, continence can generally be restored in 4-8
weeks for both fecal and urinary incontinence by using the techniques described
in this protocol, which combine clinical assessment and training with EMG biofeedback.
47
Facts and figures
48
•
Incontinence affects men and women of all age groups.
•
An estimated 60-70 % of people affected by incontinence can be cured
or improve their quality of life (Continence Foundation of Australia).
•
Physiotherapy has been proven to be a cost effective and successful form of treatment for both male and female urinary incontinence.
•
84% of women with urinary stress incontinence are cured with the help
of pelvic floor muscle training taught be physiotherapists, with most
women receiving five physiotherapy sessions (Neumann PB et al, 2005).
•
Physiotherapy (pelvic floor muscle training) has also proven to be effective in preventing urinary incontinence (Chiarelli et al 2002).
•
Physiotherapy treatment is less invasive and cheaper than pharmaceutical
and surgical options.
•
Physiotherapy care costs around $300, compared with surgery costing upwards of $4700 (Neumann et al, 2005).
•
Men who have physiotherapy after prostatectomy are significantly more
likely to regain continence after three months than men who do not (Van
Kampen, Weerdt et al, 2000).
•
The duration of symptoms is not an obstacle to success, nor is age a barrier,
as older women (60 - 80+ years) have been shown to respond extremely well
to physiotherapy for Stress incontinence. (Neumann P, Morisson S, 2008).
Unique software features
This chapter will explain the use of unique features in the myo pc software
package:
1. Fatiguability index
2. Intake and Voiding diary
3. General assessments
4. Reporting function
5. Create your own template
6. 3D animation software for children
1.
Fatiguability index
Muscle fatiguability can be defined as a decrease in the force-generating ability of
a muscle resulting from recent activity. The fatiguability index is a measurement
tool which measures the rate of decline in force-generating capacity of muscles.
The fatiguability index calculates (automatically) the maximum and minimum EMG
values of a complete treatment session. Of course, serial measurements (at least
three sequences) are needed to interpret the degree of muscle fatiguability.
49
50
Fatiguability index: more sessions selected.
If you want to compare several treatment sessions to have a detailed insight in
the patient’s muscle fatiguability progress: select in the “patient database” the
tab “documents” and select the “fatiguability index” that you want to compare.
Every treatment is linked to a trend line. For each trend line, the fatiguability
index, endurance, session date and session time is then displayed. You can easily
see the treatment outcomes and therapy progress in this window. Furthermore,
you can also print this file in a word-document for a doctor’s report.
51
2.
Intake and voiding diary
The Myo Pc software provides an “intake and voiding diary”. The voiding
diary enables the patient to record the type and amount of fluid intake, voiding
time and amount, incontinence episodes with estimated leakage volume etc for
24-hours period.
Significant information can be obtained from diary analysis, including incontinence and elimination patterns and functional bladder capacity. The voiding diary can also be used throughout treatment to assess improvement or changes in
urinary status.
In the patient database you select “voiding diaries” and than select “new intake
and voiding diary”.
52
When you click on “New Intake
and voiding diary”, the following
window appears:
53
In order to record the entire events, you have to print the document “Voiding
diary” which can be found under “documents” in the patient database menu. You
give it to the patient and he has to follow the instructions. Once you get back
this document, you can fill the “intake and voiding diary” menu in the Myo PC
software. Then you can easily store it and get a complete report with statistic.
54
3.
General assessments
In the patient database, you select” assessments”. The Myo Pc software provides
a comprehensive general assessment. The therapist can easily fill out the detailed
and relevant information which is necessary for his or her diagnostics.
The assessment can be easily filled out by the therapist and can be printed
or saved.
55
4.
Reporting function
A comprehensive (doctor’s) report in a few clicks. When clicking on the icon “Print
summary report” in the patient database dialog window, you enter a window
where you can select:
•
•
•
56
Summary of one or more available “Intake and voiding diaries”.
One or more fatigability indexes of the available sessions.
Data of the one ore more available “general assessments”.
When you selected “Create” in the dialog window, a document will be automatically generated with the general info of the patient and all the selected data you
want to add in the patient summary report.
57
5.
Create your own templates
In the “configuration of the treatment parameters and settings” you can select different predefined “themes” for your treatment. For example, a sports car
racing on the road, or a duck swimming in the water. With the use of these templates, you can make a real challenge of every treatment session!
58
6.
3D animation software for children
In the menu configuration for treatment parameters setting you can choose
several friendly and colorful 3D animations. This software is especially designed
for children and is very easy to use in your biofeedback treatment.
In the screen for “configuration of the treatment parameters and settings” you
can choose by “animation” your favorite animation and visualize the patient
self-performing in a nice 3D animation.
59
Overview probes
Characteristics
overview
Novatys
Analia
Optima 3
VB2+
Use
Vaginal
Anal
Vaginal
Vaginal
Purpose
General
General
Specific
Specific
Electrostimulation/Biofeedback
Stimulation
Biofeedback
Stimulation
Biofeedback
Stimulation
Biofeedback
Stimulation
Biofeedback
Electrodes
2 large
symmetric electrodes
2 long ring
electrodes
3 hemispheric
electroddes
2 partial ring
electrodes
Pigtail pins
female
2 mm
connector
2 mm
connector
2 m/m plug
2 m/m plug
Cable length
25 cm
22 cm
20 cm
20 cm
Total probe
length
110 mm
115 mm
120 mm
130 mm
Total weight
33 gr.
23 gr.
21 gr.
38 gr.
To treat
Whole Levator
ani elevator
branche
External anal
sphincter or
pubo-rectalis
muscles
Whole Levator
ani elevator
branche (especially for pudenda neuralgia
syndrome)
Whole Levator
ani elevator
branche, treat
asymmetry by
turning the
probe.
60
Characteristics
overview
Perisize 4+
Analys+
Vaginal pressure probe
Anal pressure
probe
Use
Vaginal
Anal
Pressure
Pressure
Purpose
Specific
Specific
Pressure probe
Pressure probe
Electrostimulation/Biofeedback
Stimulation
Biofeedback
Stimulation
Biofeedback
Feedback
Feedback
Electrodes
4 indep.
hemispheric
electrodes
2 long lateral
bar electrodes
Pigtail pins
female
2 m/m plug
2 m/m plug
Cable length
20 cm
20 cm
Total probe
length
110 mm
140 mm
Total weight
16 gr.
13 gr.
To treat
Whole Levator
ani elevator
branche, or
deep/superficial muscles, or
calming stimulation
External, anal
sphincter or
pubo-rectalis
muscles
61
References
Andrasik, F. & Blanchard, E.B. Biofeedback treatment of muscle contraction
headache. In Hatch, J.P., Fisher, J.G., Rugh, J.D., (eds.) Biofeedback: Studies in
Clinical Efficacy. NY: Plenum Press, 1987.
Arena, JG, Hannah, SL, Bruno, GM & Meador, KJ (1991). Electromyographic
biofeedback training for tension headache in the elderly: A prospective study.
Biofeedback and Self-Regulation, 4, 379-390.
Australian Institute of Health and Welfare (2006) Australian incontinence data
analysis and development report.
Basmajian, J.V. & Blumenstein, R. (1980). Electrode Placement for EMG Biofeedback. Baltimore: Williams & Wilkins.
Bo K, Berghmans B, Morkved S, Van Kampen, S.Evidence-Based Physical Therapy
for the Pelvic Floor. Edinburgh: Churchill Livingstone/ Elsevier 2007.
Bourcier AP, McGuire EJ, Abrams P. Philadelphia, PA: Pelvic floor disorders. Elsevier Saunders 2004.
Chiarelli P and Cockburn J (2002) “Promoting urinary continence in women following delivery: Randomised controlled trial”, British Medical Journal 324:12411247.
Chiarelli P, Brown W et al (1999) “Leaking Urine - Prevalence and Associated
Factors in Australian Women”, Neurourology and Urodynamics 18(6): 567-577.
Davila GW, Ghoniem G, Steven D. Wexner. Pelvic Floor Dysfunction: A Multidisciplinary Approach. London, 2006.
62
Draper V: Electromyographic biofeedback and the recovery of quadriceps femoris
muscle function following anterior cruciate reconstruction. Phys Ther 70: 11-17,
1990.
Dupuy, H.J., Engel, A., Devine, B.K., Scanlon, J., Querec, L. Selected Symptoms
of Psychological Stress, US Public Health Service Publication #1000, Series 11,
#37. National Center for Health Statistics. 1977.
Garth W, Allman F. Armstrong W: Occult anterior subluxations of the shoulder in
noncontact sports. Am J Sports Med 15:579-585, 1987.
Gowen I, Jobe F, Tibone J (1987): “A comparative electromyographic analysis of
the shoulder during pitching”. Am J Sport Med 15:586-590.
Lehrer, P. M., & Woolfolk, R. L. (Eds.)(1993). Principles and practice of stress
management (2nd ed.). New York: Guilford Press.
LeVeau B & Rodgers C(1980). “Selective training of the vastus medialis muscle
using EMG biofeedback”. Physiotherapy 60 (11): 1410-1415.
McConnell J.S.: the management of chondromalacia patellae: A long term solution. Australian J Physiotherapy 32 (4): 215-223, 1986.
McIntosh LJ, Frahm JD, Mallet VT, Richardson DA (1993) “Pelvic Floor Rehabilitation in the Treatment of Incontinence”, J. Reproductive Medicine 38 (9).
662-6.
Neumann PB et al (2005) “Physiotherapy for female stress urinary incontinence:
a multicentre observational study”, ANZJOG 45: 226-232.
Neumann et al (2005) “Costs and benefits of physiotherapy as first-line treatment for stress urinary incontinence in Australia”, Aust N Z J Public Health 29:
416-21
63
Neumann P, Morisson S (2008) “Physiotherapy for urinary incontinence”. Australian Family Physician Vol 37. No 3. March.
Newman, DK. Managing and Treating Urinary Incontinence. Health Professions
Pr. 2002.
Peper, E. (1990) Breathing for Health. Montreal: Thought Technology Ltd. Soderberg, G.L. (Ed). (1992).
Reid D, Saboe L, Burnham R: Current research of selected shoulder problems. In:
Donatelli R. (Ed.) Physical Therapy of the Shoulder. Churchill Livingston, New
York, 1987.
Reynolds L, Levin T, Medeiron J, Adler N, & Hallum A(1983): “EMG activity of the
vastus medialis oblique and vastus lateralis and their role in patellar alignment”.
American J. of Physical Medicine, 62 (2): 61-71.
Schwartz, M.S. Biofeedback: A Practitioners Guide. New York: Guiliford Press,
1987.
Selected Topics in Surface Electromyography for use in the Occupational Setting:
Expert Perspectives. U.S. National Institute for Occupational Safety and Health,
Publication No. 91-100. Available from NIOSH Publications,
Taylor, W. (1993). Surface EMG and Biofeedback Manual. Oakland, CA:
The Stens Corporation.
Van Kampen M, De Weerdt W, Van Poppel H, et al (2000) “Effects of pelvic-floor
re-education on duration and degree of incontinence after radical prostatectomy”, The Lancet 335:98.
64
Voorham- van der Zalm PJ (2008). “Towards evidence based practice in pelvic
floor physiotherapy”. Proefschrift, Leiden University Medical Center, The Netherlands.
White L, Tursky B.”Clinical biofeedback: efficacy and mechanisms”. New York:
Guilford Press, 1982.
www.bfe.org
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Notes
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