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BIOFEEDBACK
BIOFEEDBACK
Sponsor:InstituteofSpinalCordInjury,Iceland
BRUCKERMETHOD
1) Introduction
2) How It Works
3) Biofeedback for SCI
4) Questions and Answers
5) Conclusion
6) Availability
INTENTIONCONTROLLEDMYOFEEDBACK(IMF)
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voluntary and involuntary responses after being fed back information that
revealed what was occurring in their bodies. After treatments, patients
retain the ability to repeat learned responses at will, without visual or audio
feedback.
In 1969, the use of audiovisual information to train subjects to alter blood
pressure, heart rate, muscle tension, and brain activity was first termed
biofeedback. O. Hobart Mowrer pioneered the use of instruments to
control bodily functions in 1939, using alarms triggered by urine to stop
children from bedwetting. Biofeedback first gained the publics attention in
the late sixties, when it was used to demonstrate the biophysical selfcontrol
of yogis in altered mental states.
Biofeedback has been used to treat migraine headaches, tension headaches,
chronic pain, digestivesystem disorders, urinary incontinence, high blood
pressure, cardiac arrhythmias, attention deficit hyperactive disorder,
Raynauds disease, epilepsy, SCI, stroke, traumatic brain injury, cerebral
palsy, and various movement disorders.
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suggests that the movement threshold might be reached in the first or second
biofeedback session. More sessions are needed if the initial signal is lower,
but still strong enough to suggest that a muscles functional threshold might
be reached. If no signal can be found, or if no improvement can be made on
trace signals, it is unlikely that the muscles functional threshold will be
reached at that time. A clinical study involving one hundred subjects with
upper extremity SCI reported the following:
A significant increase in EMG activity occurred from the triceps
after one biofeedback treatment session and further significant
increases in EMG activity occurred after additional biofeedback
treatment sessions. Initial muscle strength and initial EMG
levels were not determining factors for response to the
biofeedback. The results suggest the efficacy of biofeedback for
increasing voluntary EMG responses in long term spinal cord
injury patients.
3) Does injury level or neurological completeness limit potential
benefits? Biofeedback therapy can lead to functional improvements in
subjects with SCI regardless of level of injury or completeness. Moreover,
MRIs are unable to accurately predict outcomes of biofeedback treatments,
because they are unable to determine the neural conductivity. Subjects with
injuries evaluated as complete have made substantial improvements
through biofeedback. Whereas others with slight to moderate incomplete SCI
have improved only slightly. According to Brucker, it is rare that biofeedback
therapy fails to exert some degree of positive effects.
4) Does time post injury affect possible effects? Biofeedback treatment
outcomes for those with SCI can be affected by time post injury for the good
or bad. Patients who had little neural sparing through the injury site soon
after injury can have considerable disused connections ready to be found and
used, once enough time elapses to permit neural repair, or remodeling. On
the down side, too much time post injury contributes to muscle atrophy,
contractures, and loss of bone density; these can all adversely affect an
individuals ability to benefit from biofeedback. For example, if a tendon
becomes to too contracted, it may be unable to respond to biofeedback
identified and strengthened signals.
5) What degree of improvement is typically seen in patients with SCI?
Brucker estimates that 98% of individuals with SCI who undergo his method
improve at least one vertebra level of functionality; therefore the condition
of an individual with cervical C7 SCI might improve to that generally found in
those with thoracic T1 injury. Ninefive percent of his patients improve two
vertebra functional levels, and 85% improve three. Improvements greater
than this are too erratic to predict. However, biofeedback improvements
may occur in functions controlled by nerves that leave the cord far below the
subjects lesion, before being seen in functions controlled by nerves that exit
the cord just below the injury site.
Depending on which muscles can be fired through biofeedback and
strengthened through rehabilitation, it may be possible for previously
wheelchairusing individuals to stand and ambulate. Specific muscles
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(quadriceps) are needed to stand, and others (hip flexors) are needed to
walk. However, the use of braces or adjusted patterns of gait might allow a
subject to stand or ambulate even if control of the quadriceps and hip
flexors is not achieved. This also applies to the muscles of the calves, feet,
and ankles, or to the upper extremities. In other words, a BFBtrained
therapist will try to improve as many functions as possible. But if some motor
functions do improve, while others do not, improvements in limb
function might still be gained.
6) How long does a typical session last for a subject with SCI? One hour.
7) Has biofeedback led to positive effects in SCI patients for urinary,
bowel, respiratory, spasticity/clonus, or pain issues? Biofeedback can
produce positive effects on urinary incontinence, bowel control, respiration,
spasticity, and clonus. It is ineffective for treating SCIrelated chronic pain.
Improved muscle tone and control of abdominal muscles can indirectly
improve bowel and bladder control. Spasticity and clonus often decrease
when improvements are made in voluntary motor signal strength. Previously
ventilatordependant subjects have improved the use of intercostal muscles,
which assists breathing with the upper chest cavity (as opposed to
diaphragmatic breathing), allowing these individuals to become ventilator
independent.
8) How many sessions are usually required to achieve maximum results?
Fifteen sessions are normally advised for a course of biofeedback treatment
for SCI.
9) What physical factors determine the outcome of biofeedback
treatments? To be effective, neural pathways must be exist between the
brain and muscles that control desired functions. Neural signals over these
connections may be weak or the connection may be dormant. But a pathway
must exist for biofeedback to exert an effect. Target muscles must be able
to respond to neural signals. Excessive atrophy and tendon contractures can
prevent the use of limbs, regardless whether a neural connection is found or
strengthened.
10) Can Biofeedback reverse muscular atrophy? Muscle mass may be
improved if biofeedback therapy leads to functional use. Moderate to severe
atrophy may require the use of therapeutic electrical stimulation to rebuilt
atrophied muscles along with biofeedback. However, an initial biofeedback
evaluation can reveal if nerve signals are present in atrophied muscles that
might lead to functional improvements once the muscles are rebuilt.
11) Are additional rehabilitation regimens recommended for biofeedback
subjects? Biofeedback is more effective when combined with other forms of
rehabilitation. For reasons discussed before, it is recommended that
individuals considering biofeedback attempt to maintain flexibility, bone
density, and muscle mass. If biofeedback therapy succeeds in identifying and
strengthening neural pathways, physical rehabilitation may optimize their
functional use.
12) Are followup treatments indicated once improvements plateau? Once
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AVAILABILITY
MainCenter
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BruckerBiofeedbackLaboratory,UniversityofMiamiSchoolof
Medicine/MJHHA,5200NE2ndAve,Miami,FL33137
(telephone:3057623882email:eroberts@mjhha.org.
OtherU.S.Centers
FloridaHospital,5165AnansonSt,Orlando,FL32804(407
3037600).
CoraRehabilitationClinic,527ELongAve,NewCastle,PA
16101(7246544545).
St.David'sRehabilitationCenter,1005E32ndSt,Austin,TX
78705(5124767111).
MaryFreeBedRehabilitationHospital,WealthySE,Grand
Rapids,MI49503(6162420360).
InternationalCenters
NeurologicalEducationCenter,BeijingRehabilitationCenter,
BeijingShijingshanDistrict,BadachuRd,Beijing,China(010
88961133,ext2204).
Dr.BernardBruckerRehabilitationCenter,SantaAnna
University,RuaVoluntarriosdaPatria#257,Santana,Sao
Paulo,Brazil02011000(551121758050).
HospitaldeNino,Apartado4087,Zona5,Panama,Republicof
Panama(0015072251583).
JerusalemCommunityHealthCenter,30TachkemoniSt,PO
Box6851,Jerusalem,Israel(01197225381820).
OrthopadischeKlinikMunchenHarlaching,Zentrumfur
Kinderorthopadie,LeitenderArztDr.med.PeterBernius,
HarlachingerStrasse51,81547Muchen,Germany(0896211
2071).
MallyaHospital,No2,VittalMallyaRd,Bangalore,India560
001(91802277979).
INTENTIONCONTROLLEDMYOFEEDBACK(IMF)
GermanscientistUlrichSchmidtdevelopedIMFtherapy,whichis
beingusedinanumberofclinics(e.g.,www.imftherapy.co.uk)to
treatavarietyofneurologicaldisorders,includingSCI.Likeother
biofeedbacktherapies,IMFisbasedonthescientificallyprovenfact
thatinmostspinalcordinjuries,eventhoseclinicallyclassifiedas
complete,someintact,albeitperhapsdormant,neuronsstill
transversetheinjurysite.Throughappropriaterehabilitative
programsandbuildinguponinherentplasticity(i.e.,adaptability)of
thenervoussystem,thesesurvivingneuronslaythefoundationfor
newfunctionrestoringneuronalnetworks,pathways,and
connections.
WithIMF,residualnervesignalsgeneratedbythementalintention
tomovemusclesbelowtheinjurysitearerecordedatthose
muscles.TheIMFdeviceamplifiesthesefaintimpulsesandthen
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sendstheamplifiedsignalsbacktothetargetmuscles.With
practice,thisprocessbuildsupnascentfunctionrestoringnetworks
and,inturn,voluntarymusclemovementandstrength.Unlike
passiveFESmusclestimulation,thepatientsintentionisthedriving
forcebehindrestoredfunction.
Atthe6thEuropeanTraumaCongress(May2004),Schmidtand
colleaguespresentedtheresultsofastudyevaluatingtheeffectsof
IMFtherapyinsubjectswithparaplegia:
19paraplegicpatientsrangingfrom1monthto43yearsafter
spinalcorddamageperformedIMFtherapywiththeaimofachieving
betterstabilityintheirbody.Afteronemonth18patientshadbetter
proprioceptivefeedbackandonepatienthadnochange.Aftertwo
months11patients(60%)wereabletointensifyvoluntarymuscle
activity.Afterthreemonths3patients(15%)wereabletostandand
walkoncrutchesorwithametalwalkeroneofthem43yearsafter
spinalcorddamage.
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