Comparing EMG Biofeedback and Tutor system movement feedback in Stroke


LIVESTRONG.COM features this article By Tamasin Wedgwood on Oct 5, 2011. In this article the American Stroke Association likens biofeedback to looking in a mirror to check that one is moving in the correct way. Electrodes measure bodily functions – heart rate, muscle movements or blood pressure – and the information is fed back to the patient. Biofeedback is mainly used in stress-related conditions, demonstrating to patients how relaxation improves symptoms. Its effectiveness after a stroke is disputed and still experimental.  However, there is growing interest in using biofeedback in stroke rehabilitation therapy.

Biofeedback takes three forms. Thermal biofeedback measures skin temperature. Neurofeedback measures brain activity and electromyography (EMG) measures muscle activity. Measurements captured by the electrodes are displayed on a monitor. A therapist explains this data to the patient. Initially by trial and error, the patient alters his behavior and the resultant readings are displayed on a screen. These changing readings provide visible evidence of how a patient’s reactions are influencing his symptoms or improving his bodily functions. In time patients learn to control their symptoms without needing the monitor.

During Stroke treatments EMG measurements of muscle activity that are not enough to effectuate movement are captured by the electrodes and displayed on a monitor. A therapist explains this data to the patient. The patient is asked to try his best to move his affected limb and is shown which technique results in the most muscle activity. EMG feedback can be used in physiotherapy and occupational therapy to help patients reeducate their limbs in movement by showing them how to control their muscle activity in order to teach them how to grip and release objects in a stroke-impaired hand.

As reported in a 2009 review in the Biofeedback Matters newsletter: Physiotherapy alone may improve grip but teaching brain injury including stroke patients to relax and release objects was harder. This is because the reflexes that control muscle activity in Stroke patients’ brains and muscles is damaged and overactive this causes continued muscle tension or spasticity when a patient desires to release an object. According to Dr. Richard Harvey of Chicago’s Rehabilitation Institute EMG Biofeedback can help to teach patients improved motor control but it cannot help patients rehabilitate a functional tasks.

The research summary shows the following examples of the effectiveness of biofeedback improving functional outcomes in stroke patients: A 1989 study from the Stroke Research Unit, Nottingham UK showed that stroke patients receiving EMG biofeedback regained more arm function than control group patients with patients with more extreme movement impairment showing the most benefit. A 1994 study from the stroke rehabilitation center in Rome showed similar benefits in biofeedback improving lower extremity leg strength. Unfortunately, many of the studies demonstrating benefits for stroke patients have been criticized for their small sample size and imprecise terminology. Dr. Robert Teasell at St. Joseph’s Health Care, London, Ontario rehabilitation hospital reviewed studies between the 1960s and 2003 he concluded that biofeedback did appear more effective than conventional therapies but larger studies are still needed. The American Stroke Association in 2006, confirmed and  updated this information by saying that up until 2006 these studies have not been done. The Tutor system established in 2004 with the aim of developing novel occupational and physical rehabilitation equipment based on the proven concepts of active exercise and biofeedback. The newly developed HandTutor and its sister devices (ArmTutor, LegTutor, 3DTutor) have become a key system in neuromuscular rehabilitation for stroke victims and those recovering from brain and spinal injuries,Parkinson’s, MS, CP and other limb movement limitations. These innovative devices implement an impairment based program with augmented motion feedback that encourages motor learning through intensive active exercises and movement practice. The HandTutor ArmTutor, LegTutor, 3DTutor consist of wearable glove and braces that detect limb movement showing the patient how much active or assisted active movement theyare actually doing. The rehabilitation software uses special rehabilitation games to set a new target for this movement in terms of the patients ability to move their limb. The devices then measure the limb movement and give feedback on the success of the patient in trying to gain this new movement objective. In this  way the patient is given movement feedback that allows the patient to understand which effort is more successful in allowing them to move their affected limb again. In this  way the Tutor system provides exercises that are challenging and motivating and allow for repetitive and intensive exercise practice. The HandTutor ArmTutor, LegTutor, 3DTutor is now part of the rehabilitation program of leading U.S. German, Italian, French and UK and other foreign hospitals.


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