BIOFEEDBACK

Biofeedback is a special form feedback that provides information directly to a patient about internal biological mechanisms. John Basmajian (the father of EMG biofeedback) defined it as a technique of using equipment(usually electronic)to reveal human beings some of their internal psychological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals. In physical rehabilitation biofeedback can be used to inform the patient about movement, muscle activity whole body balance, force, joint displacement, skin temperature, heart rate, blood pressure. It Is not only a feedback for the patient but also provides the physical therapist with very important monitoring feedback to help in evaluation, decision making and patient education.

GOALS OF BIOFEEDBACK
It is to improve motor performance by facilitating motor learning.

To use the biofeedback correctly and effectively the therapist must understand the principles of motor learning and technical limitations of biofeedback machines MOTOR LEARNING: Schimdt defined motor learning as a set processes associated with practice or experience leading to relatively permanent changes in the capacity for responding.
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It is a permanent changes in the ability to perform or respond that truly defines learning. Four primary factors that influence motor learning are Stage of learner Type of the task Feedback Practice Types of feedback Feedback can be two types INTRINSIC it is the bodys internal feedback mechanism which uses visual, auditory, vestibular, and proprioceptive mechanism. EXTRINSIC- it is derived from external source.eg biofeedback signal, external therapist comments. Two types of extrinsic feedback Knowledge of results:- KR is feedback given after performance of a task . feedback given about the outcome of the task is KR.eg- whether or not 25% partial weight bearing was maintained Knowledge of performance:- KP is feedback given during and after performance of a task and is related to how the task was performed.eg place the foot of your operated leg directly between the two crutches. Biofeedback given continuously during performance of a task is knowledge of performance feedback. Most biofeedback techniques and in fact much of the instruction given to patient by physiotherapist is KP feedback .although KP feedback is important researches have shown that KR feedback is superior in terms of retention of learned task.

PHYSIOLOGICAL FEEDBACK: pre planning is called feed forward or open loop control.

BIOFEEDBACK IN REHABILITATION: When using biofeedback the patient should 1. understand the relationship of the electronic signalto the desired functional task 2. pratise controlling biofeedback signal 3. perform the functional task until it is mastered and patient no longer need biofeedback. Biofeedback technique thus require , that patient utilize close loop control, using continuous external feedbackuntilll motor skills develop

sufficiently so th at open

loop control (where intermittent or no

feedback is used 0can be accomplished . Weinstein an d other researches have shown that a combinition of open and closed learning ,called scheduled feedback is more effective than closed loop biofeedback In scheduled feedback subjects practice the task initially with feedback following each trial , then spending increasing long periods without feedback following each trial. Apparently scheduled feedback encourages subjects to rely on normal , internal feedback mechanism s and decreases their dependence on relatively unnatural continuous biofeedback. TECHNICAL LIMITATIONS: Th eunique aspect of biofeedback is the source of information that is obtained (ie physiological mechanism )which is otherwise undetected. So, the feedback mechanism must be 1. relevant 2. accurate 3. rapid to enhance motor learning RELEVANCY: EMG biofeedback provides relevant information regarding motor unit activity ,which patient do not otherwise available and useful information is pertinent to the desired motor outcome Although the therapist can verbally describe location of the agonist and the antagonist muscle and describe the feeling the patient should experience if the muscle used appropriately, there is no way to communicate which motor unit to activate Neither too much nor too little information is given and the information is immediately applicable to the behavior.
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ACCURACY: to maximize the utility of biofeedback ,one must be certain that the type of device and the wa y it is attached provide truthful ,accurate information. Many therapist prefer to work with devices that directly measure force or joint range of motion . SPEED OF INFORMATIION:therapist must choose the instrument that provides the most meaningful information to patients.feedback must be timely to be useful. EQUIPMENT USED: The basic EMG biofeedback device includes one ground and two surface electrodes,an amplifier , an audiospeaker and a video display. It is a sensitive voltmeter with a speaker and metr attached The EMG signal is transmitted from muscles to skin through the electrodes paste ,through the electrodes then through wires to the amplifier. The important point for understanding biofeedback is that EMG signal arises prior to and occasionally independent of muscle mechanical activity, so blind reliance on EMG output can be deceiving The quality of the machine and its output are chiefly governed by 1. electrodes used 2. input impedence 3. common mode rejection ratio 4. bandwidth 5. gain 6. noise level
7. ability to cope with non EMG artifacts.

THERAPEUTIC INTERVENTATION:EMG biofeedback can be used only to help the patient increase or decrease muscle activity Thus for weak muscle the goal is to increase th e EMG signal(uptrarn) For overactive muscle the goal is to decrease the EMG signal . Biofeedback application distinguish only between weakness or over activity (ie functional classification)but not the cause of them. Typical treatment session includes : 1. patient functional assessment 2. problem identification and establishing expect ed outcomes goals of treatment 3. therapeutic intervention. Uses of imagery , PNF, ice , vibration , even electrical stimulation in con junction with biofeedback can enhance the patients motor performance so long as they do not induce artifactual feedback. Among the most useful techniques is to have the patient imagine the motor activity, and while the electrodes monitor the muscle and the therapist give verbal reinforcement and manual assistance such as tapping, tendon pressure or putting the muscle on stretch, the patient attempts to perform that activity. No matter what the diagnosis is the biofeedback technique treatment approach is similar 1. select a muscle whose EMG signal is relevant to the functional activity 2. have the patient practice controlling the signal 3. Withdraw the feedback as function is gained.