9. BIOFEEDBACK IN PHYSIOTHERAPY AND FUNCTIONAL ELECTRICAL STIMULATION 23-24.pdf

BIOFEEDBACK IN PHYSIOTHERAPY Electrophysical Agents Degree of Physiotherapy CEU-Universidad San Pablo 2023-2024 OUTLINE 1. DEFINITIONS AND BASIS. 2. SIGNAL PHASES AND ELECTRODES 3. APPLICATION 4. INDICATIONS 2 BIOFEEDBACK (BFB) • Technique to learn to control the body’s function (voluntarily...

BIOFEEDBACK IN PHYSIOTHERAPY Electrophysical Agents Degree of Physiotherapy CEU-Universidad San Pablo 2023-2024 OUTLINE 1. DEFINITIONS AND BASIS. 2. SIGNAL PHASES AND ELECTRODES 3. APPLICATION 4. INDICATIONS 2 BIOFEEDBACK (BFB) • Technique to learn to control the body’s function (voluntarily) by means of the information provided by the patient. • Patient is connected to electrical sensors to receive information (FEEDBACK) visual or auditory signals about the body (BIO). • First using biofeedback equipment, afterwards even without. 3 BIOFEEDBACK (BFB) • ‘ A set of therapeutic procedures that uses electronic or electromechanical instruments to measure and provide the patient with information with educational and reinforcing properties about their physiological activity in an immediate, timely and accurate manner. 4 BIOFEEDBACK • LEARNING: – RETRAINING OF NEW FUNCTIONS. – NEW FUNCTIONS • LEARNING: – AFTER RECEIVING INFORMATION ABOUT HIS BEHAVIOUR’S CONSEQUENCES. 5 BIOFEEDBACK BASIS • BIOFEEDBACK IS AN INSTRUMENT-BASED LEARNING PROCESS BASED ON OPERANT CONDITIONING TECHNIQUES. • PRINCIPLES: – REINFORCEMENT. – MODELLING. – GENERALIZATION. 6 OPERANT CONDITIONING • A learning process in which the likelihood of a specific behaviour is increased or decreased through positive or negative reinforcement each time the behaviour is exhibited, so that the subject comes to associate the pleasure/displeasure of the reinforcement with the behaviour. Operant conditioning, sometimes referred to as instrumental conditioning, is a method of learning that uses rewards and punishment to modify behavior. 7 REINFORCEMENT •Consequence that will strengthen an organism's future behavior whenever that behavior is preceded by a specific previous stimulus. •Action which increases a behaviour •Acoustic/Visual •Positive/Negative •Continuous/intermittent – Intermittent: • Fixed/Variable 8 REINFORCEMENT • • Positive occurs when desirable stimulus is presented as a consequence of a behaviour and the behaviour increases. Negative occurs when an aversive stimulus is removed or prevented from happening and the rate of a behaviour increases. •Continuous occurs every time there is correct response. •Intermittent occurs every certain responses or certain time. • Fixed: Every X contractions. • Variable: Subject does not know when the reinforcement is coming. 9 MODELLING • Progressive reinforcement. • To motivate the subject. 10 GENERALIZATION • When subject can perform the movement without using the biofeedback equipment. 11 BIOFEEDBACK SIGNAL’S PHASES • DETECTION • AMPLIFICATION • FILTRATION • PROCESSING • CONVERSION AND PRESENTATION. 12 DETECTION: SENSORS • ELECTRODES: DIRECT SIGNALS – Surface. • TRANSDUCTORS: INDIRECT OR PHYSICAL SIGNALS – Physical signals • Temperature – Implanted. – Special. • Electrogoniometer • Plethysmography • Pressure probes (bladder and vagina) – Indirect signals • Skin impedance 13 SPECIAL ELECTRODES: INTRACAVITARY (PRESSURE ELECTRODES) 14 ELECTRODES • SURFACE: – 1 GROUND ELECTRODE – 2 ACTIVE ELECTRODES 15 ELECTRODE PLACEMENT • ALWAYS OVER THE SAME PLACE. • Clean the area. • Active: – Distance 1-2 cm. • Neutral: – Big muscles: between active electrodes – Small muscles: next to active /bony prominence 16 APPLICATION PROTOCOL • PATIENT’S ASSESSMENT. • BASELINE OUTLINE. • SETTING OF TARGETS 17 BASELINE OUTLINE • CLEAR INSTRUCTIONS • ADAPTION TO THE EQUIPMENT • STABLISH THE STARTING POINT (SCALE). • 3 STEPS : – Rest. – Minimum contraction. – Maximum contraction. 18 DATA RECORDING 19 SETTING OF TARGETS A. Physiological function’s awareness. B. Voluntary control of the physiological function. C. Control the physiological function without using the equipment. 20 SESSIONS AND DURATION • NUMBER OF CONTRACTIONS. • 30-60 MINUTES. 21 INDICATIONS • TMJ DISORDER Temporomandibular joint • STRESS DISORDERS (BRUXISM, HEADACHES) • URINARY/ANAL INCONTINENCE. • MUSCLE TRANSPOSITION • SWALLOWING DISORDERS • NERVOUS AND PERIPHERAL SYSTEM INJURIES. • CHRONIC PAIN • MUSCLE ATROPHY 22 INDICATIONS 23 CONTRAINDICATIONS????? • PACIENT’S COGNITIVE LEVEL 24 FUNCTIONAL ELECTRICAL STIMULATION (FES) • CONCEPT • TECHNIQUE DESCRIPTION • ELECTRICAL PARAMETERS • ELECTRODES • FES APPLICATIONS 25 CONCEPT OF FES • The use of electrical stimulation to increase muscle activity in individuals who suffered from neurological conditions • Aim: To improve or produce a functional movement. • Locomotive system functions: standing, gait, pedaling, pincer grasp… 26 PATIENT’S SELECTION • Peripheral Nervous System (PNF) should be undamaged. • Suitable response to Neuromuscular Electrical Stimulation. • Lack of limitations or joint alterations of the involved joints. • Knee/Hip arthrosis may be a contraindication for FES for standing and gait. • Severe spasticity and muscle retractions stop FES application. • Functional proximal muscles should be preserved. 27 PATIENT’S SELECTION • Skin where electrodes are placed should be in good conditions. • Patient should be encouraged and have cognitive skills and learning abilities to handle FES system. • Not to suffer from autonomic dysreflexia or regular vegetative crises. • Lack of severe osteoporosis or recent fractures especially in the lower limbs which support body weight during a FES system for standing and gait. PATIENT’S SELECTION • FES for standing requires • enough strength in the upper limbs, certain degree of balance and patient being independent during transfers. • good cardio-respiratory conditions (intense effort during gait). • morbid obesity and not controlled contraindications for standing and gait. hypertension are • good orthostatic adaptation to maintain the standing position without hypotension or dizziness. MUSCLE RECONDITIONING • • Start earlier to: • Improve the muscle trophism and avoid atrophy • Recover the neuromuscular function of the partial preserved muscles. • 6-8 channels if possible. Strength, endurance or both (depending on the muscles) • More endurance because slow fibers are the first damaged in a neurological injury. FUNCTIONAL TRAINING • Functional training with the specific FES device to: o To teach the patient or family o The different electrode placement. o The device working. o The contractions’ control using the controls. INTEGRATION IN ACTIVITIES OF DAILY LIVING • Use of FES in activities of daily living. • For example: Upper limb FES should be used with eating and hygienic habits, etc. ELECTRICAL PARAMETERS • BURST of pulses to produce a tetanic contraction. • Progressive intensity: Ramp Up and down to allow progressive contraction and relaxation to avoid antagonistic muscle spasms due to the sudden stretching. • Symmetrical balanced pulses (no galvanic component). ELECTRICAL PARAMETERS •Pulse duration: 100-500µsg------1000µsg. •More than 20 Hz (20-40 Hz): +50 Hz (type II fibers) muscle fatigue (FES disadvantage). •Intensity: • To produce a muscle contraction to the function (grasping, standing, gait) • Controlled by the patient, biofeedback system or preset. ELECTRODES • SURFACE ELECTRODES (TRANSCUTANEOUS) o Easy application • IMPLANTED INTERNAL ELECTRODES (PERCUTANEOUS): o Application from acute phases o Deep muscles. o Allow electrode placement o More selective. o Early phases: surface electrodes and then implanted electrodes. o Less time to put into operation. o More independence and function. o Disadavantages: o Invasive technique o Every electrode failure: surgery. o Difficult removal. o Wait for its implantation: 18 to 24 months (chronic without recuperation possibilities) FES APPLICATIONS • STANDING AND GAIT DEVICES • ANTI-EQUINUS DEVICES • UPPER LIMB DEVICES • PEDAL DEVICES 36 STANDING ANG GAIT DEVICES • INDICATIONS: o Spinal cord injuries o Cerebral palsy o Hemiplegia o CNS disorders. • USE: Alone or in combination (FES+orthosis= hybrid system) • DISADVANTAGES: fatigue, esthetic and complex system, time needed to connect and disconnect and relative functional recovery. STANDING ANG GAIT DEVICES Parastep I System® • Surface electrodes. • Six channels (12 electrodes): 3 for each limb, 2 channels to stimulate bilaterally the quadriceps, 2 for the peroneal nerves and 2 more for the gluteus maximus and minimus or for the paraspinal muscles to produce extension and enable balance. • The quadriceps are stimulated to stand up and to maintain the standing position. • https://centuryorthotics.com/parastep-system/ STANDING ANG GAIT DEVICES Parastep I System® • Peroneal nerve: produces triple flexion reflex (knee and hip flexion and ankle dorsiflexion) allowing to step up and after 1 second the software activates the cuadriceps channel of this leg to allow the support. • Stimulation sequences: patient presses buttons on the walker. • Intensity stimulation control: preprogrammed intensity. included in the software using a FES FOR STANDING AND GAIT IMPLANTED ELECTRODES • System with 12-34 implanted electrodes, several models: • Muscle response is greater because electrodes are placed directly over the muscle or the nerve. • Electrodes implanted in every muscle related to the gait. • Disadvantage: surgical technique. FES FOR STANDING AND GAIT HYBRID ELECTRODES • Surface FES or implanted FES with orthosis. • Ankle-foot orthosis (AFO), Knee-ankle-foot orthosis (KAFO), or more complex systems (gait robots) • Reduced use. FES FOR STANDING AND GAIT • ADVANTAGES • DISADVANTAGES: • Decreases of muscle atrophy. • Reduce use. • Muscle circulatory and morphological changes. • Great physical strain. • Early fatigue apparition: • Cardiorespiratory training. • Prevents thrombosis and cardiovascular diseases. • Improves intestinal and bladder function. • Prevents pressure ulcers apparition. • Phychosocial benefits • Improve self-esteem o used for short distances o home use o flatland gait. ANTI-EQUINUS DEVICES • More used in clinical practice. • Adult hemiplegic, certain spinal cord injuries, infantile cerebral palsy or multiple sclerosis. • Improve the gait: • In patients with no voluntary control of ankle dorsiflexors. • Great lower limb extensor spasticity. https://www.youtube.com/watch?v=6jD3jpb5jFA ANTI-EQUINUS DEVICES • gait speed • Improves ankle kinematics • Prevents orthopedic deformities • Reduces spasticity • Facilitates motor learning. CEFAR Step II® ODFS® https://www.youtube.com/watch?v=cZ0HGEWQJB8&t=86s CEFAR Step II® AND ODFS® (Odstock Dropped Foot Stimulator). • Surface electrodes. • With a pressure sensor placed on the heel inside the footwear and a channel placed on the peroneal nerve to facilitate the ankle dorsiflexion and the knee and hip flexion during the swing phase. • When the swing phase starts, the sensor detects a pressure reduction and the peroneal nerve is activated to produce ankle dorsiflexion. • When the stance phase starts, the sensor detects a pressure increase and the stimulation is interrupted, allowing a total plantar contact. OTHER ANTI-EQUINUS SYSTEMS • Wireless systems. • Implanted devices. Functional Device NESS L300 https://www.youtube.com/watch?v=43m_vvcGUV0 ActiGait System UPPER LIMB DEVICES • To restore hand function: Grip strength and pincer grasp. • Hemiplegic and spinal cord injuries. • Benefits: • Induce plasticity corticospinal phenomenon • Great activation of sensory motor cortex • Improve patient functional recovery. HANDMASTER NESS H200™ and FREEHAND SYSTEM® (More used and approved by the FDA) HANDMASTER NESS H200™ • An hybrid system. • Orthosis to stabilize the wrist in a functional position. • 5 integrated surface electrodes to stimulate the muscles: 2 over the flexor digitalis superficialis and flexor pollicis longus, 2 over the extensor digitorum longus and extensor pollicis longus and brevis and 1 electrode over the thenar eminence. • Function: Pressure button. https://www.youtube.com/watch?v=Px6CJUfZOhQ&t=89s FREEHAND SYSTEM® • Implanted device with 8 channels. • Electrodes in the epimysium muscles of the forearm and hand. • Connected through subcutaneal wires to an implanted stimulator in the chest. • Stimulation is controlled with the contralateral movements (pincer grasp with shoulder antepulsión). shouder PEDAL DEVICES • Known as FES–cycling • Combine computerized stationary bicycle with FES system to stimulate muscles involved in pedal. • Effective: • To prevent bone demineralization. • To reduce muscle atrophy and spasticity. • As an exercise to improve cardiorespiratory and vascular capacity CONCLUSIONS • Great benefits for neurological patients: functional and phychosocial. • Therapeutic and preventive use in local and systemic disorders related to neurological diseases. • Early use may improve the prognosis after the injury. • Research in neuroscience and biotechnology allow the FES future development for the activities of daily living. BIBLIOGRAFÍA • Giggins OM, Persson UM, Caulfield B. Biofeedback in Rehabilitation. J Neuroeng Rehabil 2013;10:60 • Watson T, Nusbaum EL. Modalidades en electroterapia. Madrid: Elsevier. 2021 • Albornoz M, Maya J, Toledo JV. Electroterapia Práctica. Avances en Investigación clínica. Madrid: Elsevier.2016 • Rodriguez Romero B et al. Fisioterapia con miofeedback en la transposición muscular del temporal para control de la oclusión ocular. Fisioterapia.1998; 20: 32-38. 53 Bibliografía • Avendaño, J, Basco JA. Electroestimulación funcional en el lesionado medular. Fisioterapia 2001;23(monográfico 2):12-22. • Watson T. Electroterapia. Práctica basada en la evidencia. Elsevier. 2009.Barcelona. • Cano de la Cuerda R., Collado S. Neurorrehabilitación. Métodos específicos de valoración y tratamiento. Panamericana 2012. • Watson T, Nusbaum EL. Modalidades en electroterapia. Madrid: Elsevier. 2021 • Albornoz M, Maya J, Toledo JV. Electroterapia Práctica. Avances en Investigación clínica. Madrid: Elsevier.2016