Biofeedback

Biofeedback
• A therapeutic procedure which uses electronic
or electromechanical instruments to
accurately measure, process, and feedback
reinforcing information via auditory or visual
signals
• Used to help patient develop greater voluntary
control of either neuromuscular relaxation or
muscle re-education following injury
 Role of Biofeedback
• Feedback includes information related to
the sensations associated with movement
itself as well as information related to the
result of the action relative to some goal or
objective
 Role of Biofeedback
• Feedback refers to intrinsic information inherent to
movement including kinesthetic, visual, cutaneous,
vestibular, and auditory signals collectively termed
as response produced feedback
• Also refers to extrinsic information or some
knowledge of results presented verbally,
mechanically, or electronically to indicate the
outcome of some movement performance
 Role of Biofeedback
• Feedback is ongoing, in a temporal sense,
occuring before, during, and after any
motor or movement task
• Feedback from some measuring instrument
which provides moment to moment
information about a biologic function is
referred to as biofeedback
 Role of Biofeedback
• Provides patient with a chance to make
correct small changes in performance which
are immediately noted and rewarded so that
eventually larger changes or improvements
in performance can be accomplished
• Goal is to train patient to perceive changes
without the use of a measuring instrument
so that they can practice by themselves
 Biofeedback Instrumentation
• Designed to monitor some physiologic event,
objectively quantify these monitorings, and
interpret the measurements
• Biofeedback units cannot directly measure a
physiologic event but they record some aspect
which is highly correlated with the physiologic
event
 Biofeedback Instrumentation
• Biofeedback reading gives an indication of a
physiological process but should not be
confused with the physiological process itself
 Biofeedback Instruments
 Peripheral skin temperatures measures the extent
of vasoconstriction or vasodilation
 Finger phototransmission units (photoplethysmograph)
measures vasoconstriction and vasodilation
 Units that record skin conductance activity indicating
sweat gland activity
 Units that measure electromyographic activity (EMG)
indicating amount of electrical activity during muscle
contraction
 EMG Biofeedback
• Nerve fiber conducts an impulse to the
neuro- muscular junction where acetylcholine binds
to receptor sites on the sarcolemma
inducing a depolarization of the muscle fiber which
creates movement of ions and thus an electrochemical
gradient around the muscle fiber
• Changes in potential difference or voltage associated
with depolarization can be detected by an electrode
placed in close proximity
 Measuring Electrical Activity
• EMG does not measure muscle contraction
directly
• EMG measures electrical activity associated
with muscle contraction
• Electrical activity of muscle measured in
microvolts (1 volt=1,000,000 µV)
• EMG readings can be compared only when the
same equipment is used for all readings
Measuring Electrical Activity
 EMG biofeedback unit receives small amounts
of electrical energy generated during muscle
contraction through electrode
 Separates or filters electrical energy from other
extraneous electrical activity on skin and
amplifies the EMG electrical energy
 Amplified EMG activity is then converted to
some type of information which has meaning to
the patient
Anatomy of EMG Biofeedback
 EMG Electrodes
• Skin surface electrodes most common while
indwelling electrodes are not practical
• Electrodes made of stainless steel or nickel- platted
brass recessed in a plastic holder
• Some electrodes permanently attach to cable wires
while others may snap onto the wire
• Some units include a set of three electrodes
preplaced on a velcro band which attachesto the
skin
 EMG Electrodes
• Size of electrodes ranges between 4mm in
diameter for recording small muscle activity
and 12.5 mm for larger muscles
• Increasing the size of the electrode will not
cause an increase in the amplitude of the signal
• Electrodes may be disposable or non-
disposable and require some type of conducting
gel
 EMG Electrode Placement
• Skin must be appropriately prepared by
scrubbing with an alcohol-soaked prep pad
• Electrodes should be placed as near to the
muscle being monitored as possible
• Electrodes should be parallel to the direction of
the muscle fibers
• Spacing of the electrodes is critical to reduce
extraneous electrical activity (noise)
 Separation and Amplification of
EMG Activity
• Electrode arrangement
must eliminate noise
• 2 active electrodes and
1 reference electrode
• Active electrodes pick
up electrical activity
from motor units
firing in the muscles
beneath the electrodes
 Separation and Amplification of
EMG Activity
• Magnitude of the
small voltages
detected by each
active electrode will
differ with respect to
the reference electrode
creating two separate
signals
 Separation and Amplification of
EMG Activity
• Two signals are fed to a
differential amplifier which
subtracts the signal from
one active electrode from
the other active electrode
• Differential amplifier uses
reference electrode to
compare the signals of the
two active electrodes
 Separation and Amplification of
EMG Activity
• This in effect cancels out
or rejects any components
that the two signals
coming from the active
electrodes have in
common thus amplifying
the difference between
the signals
 Separation and Amplification of
EMG Activity
• Ability of the differential
amplifier to eliminate the
common noise between
active electrodes is
called the common
mode rejection ratio
(CMRR)
 Separation and Amplification of
EMG Activity
• External noise can be
reduced by using filters
which make amplifier
sensitive to some incoming
frequencies and less
sensitive to others
• Amplifier will pick up
signals only at bandwidth
produced by electrical
activity in the muscle
 Converting EMG Activity to
Meaningful Information

• After amplification and filtering the EMG signal

indicates true electrical or raw EMG activity in muscle
• Raw EMG is an alternating voltage - direction or
polarity is constantly reversing
 Converting EMG Activity to
Meaningful Information

• To determine the overall increase and decrease in electrical

activity deflection toward the negative pole must be flipped
upward toward the positive pole
• This summation of electrical activity is referred to as rectification
 Converting EMG Activity to
Meaningful Information

• Once rectified EMG signal can be smoothed to

eliminate the peaks and valleys or high frequency
fluctuations which are produced with a changing
electrical signal
 Converting EMG Activity to
Meaningful Information

• Once smoothed the signal may be integrated by measuring

the area under the curve for a specified period of time
• Integration forms the basis for quantification of EMG
activity.
 Converting EMG Activity to
Meaningful Information
• Biofeedback units generally provide either
visual or auditory feedback relative to the
quantity of electrical activity
• Visual feedback uses lights, bars, or
analogue or digital meters
• Auditory feedback uses increasing or
decreasing tones, buzzing, beeping or
clicking.
 Setting Sensitivity
• Signal sensitivity or signal gain may be set
• Sensitivity may be set at 1 µV, 10 µV, or 100
µV
• A high signal gain means the biofeedback
unit is sensitive enough to detect the smallest
amounts of electrical activity
High sensitivity levels should be used during
relaxation training
 Setting Sensitivity
• Low sensitivity gain should be used in muscle-
reeducation during which the athlete may
produce several hundred µV of EMG activity
• When adjusting the sensitivity range it should
be set at the lowest level that does not elicit
feedback at rest
 Clinical Applications
• Muscle Re-education
Involves regaining neuromuscular control and/or
increasing strength of a muscle
• Relaxation of muscle spasm or muscle guarding
• Pain reduction
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