Biofeedback – Upper Extremity

Evidence Reviewed as of before: 26-10-2010

Author(s)*: Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jamie Bitensky, MSc OT; Mark Speechley, MD; Nicol Korner-Bitensky, PhD OT

Patient/Family Information

Introduction

Biofeedback (BFB) is commonly used as a treatment intervention for stroke rehabilitation. Following a stroke, the main central motor pathways that regulate normal muscle tone and functioning can be disrupted or even damaged. However, some motor pathways that are often unused remain relatively unaffected by the stroke. Individuals may learn how to activate these unused pathways with the help of electromyographic biofeedback (EMG-BFB) and this may lead to improvements in their muscle tone and functioning. Given that hemiparesis of the upper extremity can result in functional disability following stroke and can affect important aspects of daily living (i.e. feeding and dressing), the use of EMG-BFB as an effective means of treatment for upper extremity hemiparesis has been carefully studied. Specifically, studies have examined the use of biofeedback to improve hand function as well as upper extremity range of motion and function.

Patient/Family Information

Author: Marc-André Roy, MSc.

What is biofeedback for the upper extremity?

A stroke can damage the central nervous system and disrupt normal regulation of muscle tone. This can prevent your muscles from functioning adequately. With the help of electromyographic biofeedback (EMG-BFB), you can receive feedback to know when your muscles are tense or relaxed. Electromyography (EMG) is when a set of electrodes is placed on the skin over the chosen muscle (or muscle group) to detect the electrical signals that occur when a muscle is tense (or contracted). This electrical signal will provide you with a visual or auditory feedback to know whether or not your muscle is contracting and indicate the amount of contraction. This biofeedback can help you re-educate your muscles to contract or relax at your own will in order to increase voluntary muscle control.

Does it work for stroke?

Research has shown that the main reason for functional impairment following a stroke is upper extremity hemiparesis which can affect important activities of daily living (e.g. feeding and dressing). Biofeedback (BFB) is commonly used as a treatment intervention for stroke rehabilitation. Following a stroke, the main central motor pathways that regulate normal muscle tone and functioning can be disrupted or even damaged. However, some motor pathways that are often unused remain relatively unaffected by the stroke. Individuals may learn how to activate these unused pathways with the help of electromyographic biofeedback (EMG-BFB) and this may lead to improvements in their muscle tone and functioning. Specifically, studies have examined the use of biofeedback to improve hand function as well as upper extremity range of motion and function. There is conflicting evidence that biofeedback interventions are effective for improving upper extremity function post-stroke. But, they are not effective for improving manual dexterity and for improving range of motion in the upper extremity post-stroke. At the follow-up evaluation, biofeedback interventions were not effective for improving upper extremity function.

Who provides the treatment?

Biofeedback for the upper extremity is typically performed by a physiotherapist. Most rehabilitation centers and private clinics are equipped with EMG equipment.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Six studies, four high quality RCTs and two of fair quality , have investigated the effect of biofeedback interventions on stroke rehabilitation. Specifically, studies have investigated the effectiveness of biofeedback to improve manual dexterity, upper extremity function and range of motion (ROM).

Results Table

View results table

Outcomes

Upper extremity function

Conflicting

Three high quality RCTs and one fair quality RCT have investigated the relationship between biofeedback treatment upper extremity function post-stroke. Two studies, Basmajian et al. (1982) and Basmajian et al. (1987) investigated the effect of biofeedback compared to physical therapy using the biofeedback approach. No significant differences were observed in upper extremity function, as assessed using the Upper Extremity Function Test. Similar results were found in a similar study by Prevo et al. (1982) as assessed using a non-standardized functional test.

One high quality RCT (Crow et al. 1989) compared the use of EMG biofeedback therapy to sham biofeedback. The treatment group scored significantly higher on the Action Research Arm Test and on the Brunnstrom-Fugl Meyer Test. However, these results were not maintained at follow up.

Conclusion: There is conflicting evidence (Level 4) from three high quality RCTs and one fair quality RCT, that biofeedback interventions are effective for improving upper extremity function post-stroke. However, at follow-up there is strong evidence that biofeedback interventions are not effective for improving upper extremity function post-stroke.

Upper extremity manual dexterity

Not Effective

Two high quality RCTs investigated the relationship between biofeedback treatment and manual dexterity post-stroke. In the first, Basmajian et al. (1982) examined manual dexterity and biofeedback using the Minnesota Rate of Manipulation test. No improvements in manual dexterity were noted for either group. This finding was substantiated by another high quality RCTs Basmajian et al. (1987) that also investigated biofeedback interventions and manual dexterity. Results were similar to those found in the previous study, such that no significant differences were noted when the Finger Oscillation Test was used as a measure of manual dexterity.

Conclusion: There is strong (level 1a) evidence from two high quality RCTs, that biofeedback interventions are not effective for improving manual dexterity post-stroke.

Upper extremity range of motion

Not Effective

Two RCTs have investigated the efficacy of biofeedback treatment for improving range of motion (ROM) in the upper extremity post-stroke. One high quality RCT (Hurd et al. 1980) investigated the relationship between biofeedback and range of motion using measures of active range of motion and muscle activity in the upper extremity. No significant differences were noted. One fair quality RCT (Greenberg and Fowler, 1980) also examined the use of biofeedback methods for improving the active elbow extension ROM. No significant improvements were reported in either group.

Conclusion: There is moderate evidence (Level 1b) from one high and one fair quality RCT, that biofeedback interventions are not effective for improving range of motion in the upper extremity post-stroke.

References

Basmajian JV, Gowland CA, Finlayson MA, Hall AL, Swanson LR, Stratford PW, Trotter JE, Brandstater ME. (1987). StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. treatment: comparison of integrated behavioral-physical therapy vs traditional physical therapy programs. Arch Phys Med Rehabil, 68 (5 Pt 1), 267-272.

Basmajian, Gowland, Brandstater, Swanson, Trotter (1982). EMG feedback treatment of upper limb in hemiplegic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients: a pilot study. Arch Phys Med Rehabil, 63(12), 613-616.

Crow, Lincoln, Nouri, De Weerdt (1989). The effectiveness of EMG biofeedback in the treatment of arm function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Int Disabil Stud, 11, 155-160.

Greenberg, Fowler (1980). Kinesthetic biofeedback: a treatment modality for elbow range of motion in hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. Am J Occup Ther, 34(11), 738-743.

Hurd, Pegram, Nepomuceno. (1980). Comparison of actual and simulated EMG biofeedback in the treatment of hemiplegic patients. Am J Phys Med, 59(2), 73-82.

Prevo, Visser, Vogelaar (1982). Effect of EMG feedback on paretic muscles and abnormal co-contraction in the hemiplegic arm, compared with conventional physical therapy. Scand J Rehabil Med, 14(3), 121-131.