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Biofeedback & Physical Therapy

Biofeedback is a tool used that uses myoelectrical signals to help retrain muscles. It can be used to either increase or reduce muscle activity depending on the goal and injury. Over the last decade, several studies have supported the use of biofeedback for musculoskeletal and neurological rehabilitation. Although research originally focused on the quadriceps and knee, evidence has since expanded to include the use of biofeedback for other orthopedic conditions and injuries. Let’s look at some ways biofeedback is used in physical therapy rehabilitation to address different injuries and conditions.

 KNEE:

After knee surgery, quad weakness and loss of neuromuscular firing are very common, sometimes for over 6 months.1 After menisectomy, several studies have addressed the benefit of biofeedback on recovery. Akkaya et al. found EMG-biofeedback to be effective at reducing time on crutches, increasing quadriceps recruitment, and speeding up the rehabilitation process.2 Kirnap et all found improvements in range of motion (ROM), overall function, and max quadricep recruitment with biofeedback.3 After meniscus repair, biofeedback was shown to help improve muscular control, coordination, and function during activities.4 Benefits were even seen after total knee arthroscopy in gait and quality of life when biofeedback interventions were included in rehab.5–7

The most recent addition to the knee literature has been the support of EMG biofeedback for patellar femoral pain. The use of real time visual biofeedback was shown to improve the relative contraction strength of both vastus lateralis (VL) and vastus medialis obliques (VMO) muscles subsequently enhancing activation during daily activities.8 In a study by Alonazi et al, after just four weeks of a biofeedback guided rehabilitation program, young males with patellar femoral pain had less pain, improved strength, and long-term function.9 

HIP:

More recently, studies on the hip have yielded promising results for the use of EMG biofeedback after total hip arthroscopy. In 2019, Doctors Soni and Samuel demonstrated a conventional rehabilitation program with the use of biofeedback produced superior outcomes compared to a conventional rehab programs alone.10 Following hip arthroscopy, the use of biofeedback can be essential in helping to regain stability and improve overall athletic function following FAI and labral surgery.

SHOULDER:

Studies published on the shoulder have supported the effects of EMG biofeedback for muscle patterning and rotator cuff activation for conditions such as shoulder instability, impingement, and rotator cuff repairs. For instance, Lim et al found the use of visual EMG biofeedback to be a clinically effective training tool for increasing activation and strength of the infraspinatus muscle during specific exercises while reducing the use (substitution) of the posterior deltoid.11 Scapular dyskinesis, or poor motor patterning, is an issue with many shoulder pathologies and a focus of all scapular strengthening programs. Recently in 2020, Du et al. demonstrated that the use of visual biofeedback can help improve muscle activation and control during overhead shoulder elevation.12 Similarly, Huang et al. showed this improved scapular muscular balance during rehab exercise was beneficial for improving symptoms associated with shoulder impingement. 13 Furthermore, the use of biofeedback has evolved to incorporate interventions that work to reduce activation or down regulate an overactive muscle group that often causes pain and dysfunction, particularly the upper traps when discussing the shoulder. 

ANKLE/FOOT:

The main focus of biofeedback use in the ankle and foot has typically pertained to gait and stroke recovery. In this arena, it has been shown to improve strength, balance, and gait patterning.14 Additionally, a recent study by Kim and Uhm showed the effectiveness of biofeedback for improving balance and lower limb muscle in athletes with functional ankle instability.15 

SUMMARY:

Visual biofeedback as an adjunct for physical therapy intervention has really been transformed and modernized over the last several years. The use of visual biofeedback has demonstrated greater increases in muscle activation and greater improvements in exercise form compared to verbal and audio feedback. 3 When muscle activation is minimal, simply being able to see changes in muscle activation levels is a huge motivating factor for patients. Furthermore, it gives them a goal, purpose, and intention to their training that they are likely missing.  For one study, real time visual biofeedback on quad muscle activation was provided to assist participant’s in maintaining a sustained quadriceps contraction. 4

sEMG biofeedback is a low-risk intervention, with high levels of versatility and the ability to customize treatment to achieve functional goals faster. New evidence and studies encourage the use of EMG biofeedback as an effective and innovative treatment intervention for physical therapy. 

References 

  1. Glatthorn JF, Berendts AM, Bizzini M, Munzinger U, Maffiuletti NA. Neuromuscular function after arthroscopic partial meniscectomy. Clin Orthop Relat Res. 2010;468(5):1336-1343. doi:10.1007/S11999-009-1172-4
  2. Akkaya N, Ardic F, Ozgen M, Akkaya S, Sahin F, Kilic A. Efficacy of electromyographic biofeedback and electrical stimulation following arthroscopic partial meniscectomy: a randomized controlled trial: http://dx.doi.org/101177/0269215511419382. 2011;26(3):224-236. doi:10.1177/0269215511419382
  3. Kirnap M, Calis M, Turgut AO, Halici M, Tuncel M. The efficacy of EMG-biofeedback training on quadriceps muscle strength in patients after arthroscopic meniscectomy. 1224;118:1224.
  4. Oravitan M, Avram C. The Effectiveness of Electromyographic Biofeedback as Part of a Meniscal Repair Rehabilitation Programme. ©Journal Sport Sci Med. 2013;12:526-532. http://www.jssm.org. Accessed November 4, 2021.
  5. Nakandala N. EMG-Biofeedback Therapy in Knee Rehabilitation: A Review. 2019.
  6. Zeni J, Abujaber S, Flowers P, Pozzi F, Snyder-Mackler L. Biofeedback to promote movement symmetry after total knee arthroplasty: A feasibility study. J Orthop Sports Phys Ther. 2013;43(10):715-726. doi:10.2519/JOSPT.2013.4657
  7. Levinger P, Zeina D, Teshome AK, Skinner E, Begg R, Abbott JH. A real time biofeedback using Kinect and Wii to improve gait for post-total knee replacement rehabilitation: A case study report. Disabil Rehabil Assist Technol. 2016;11(3):251-262. doi:10.3109/17483107.2015.1080767
  8. Ng GYF, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ratio of the medial and lateral vasti muscles in subjects with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2008;18(1):128-133. doi:10.1016/J.JELEKIN.2006.08.010
  9. Alonazi A, Hasan S, Anwer S, et al. Efficacy of Electromyographic-Biofeedback Supplementation Training with Patellar Taping on Quadriceps Strengthening in Patellofemoral Pain Syndrome among Young Adult Male Athletes. Int J Environ Res Public Health. 2021;18(9):4514. doi:10.3390/IJERPH18094514
  10. Krupa D, Soni MM. To compare the effectiveness of Neuromuscular electrical stimulation and Electromyography biofeedback in individuals following Total Hip arthroplasty. 2019;07. doi:10.18535/jmscr/v7i10.06
  11. Lim O, Kim J, Song S, Cynn H, Yi C. Effect of Selective Muscle Training Using Visual EMG Biofeedback on Infraspinatus and Posterior Deltoid. J Hum Kinet. 2014;44(1):83. doi:10.2478/HUKIN-2014-0113
  12. Du WY, Huang TS, Chiu YC, et al. Single-session video and electromyography feedback in overhead athletes with scapular dyskinesis and impingement syndrome. J Athl Train. 2020;55(3):265-273. doi:10.4085/1062-6050-490-18
  13. Huang HY, Lin JJ, Guo YL, Wang WTJ, Chen YJ. EMG biofeedback effectiveness to alter muscle activity pattern and scapular kinematics in subjects with and without shoulder impingement. J Electromyogr Kinesiol. 2013;23(1):267-274. doi:10.1016/J.JELEKIN.2012.09.007
  14. Aiello E, Gates DH, Patritti BL, et al. Visual EMG biofeedback to improve ankle function in hemiparetic gait. Annu Int Conf IEEE Eng Med Biol – Proc. 2005;7 VOLS:7703-7706. doi:10.1109/IEMBS.2005.1616297
  15. Kim J-H, Uhm Y-H. Effect of Ankle Stabilization Training Using Biofeedback on Balance Ability and Lower Limb Muscle Activity in Football Players with Functional Ankle Instability. J Korean Phys Ther. 2016;28(3):189-194. doi:10.18857/JKPT.2016.28.3.189