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International Research Journal of Advanced Engineering and Science
ISSN (Online): 2455-9024
47
N.D.P.U. Nakandala, ―EMG-Biofeedback Therapy in Knee Rehabilitation: A Review,‖ International Research Journal of Advanced
Engineering and Science, Volume 4, Issue 3, pp. 47-52, 2019.
EMG-Biofeedback Therapy in Knee Rehabilitation: A
Review
N.D.P.U. Nakandala
Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, 20400, Sri Lanka
Abstract— Biofeedback (BFB) is a process where an individual’s
physiological responses are identified, measured and then provide
feedback in the form of visual, auditory or tactile in the real time. If
the individual’s physiological responses are not normal, in order to
regulate or correct them, feedback is provided via various cues
mentioned above. As the magnitude of the abnormality or the
correction can be instantly generated, this is identified as a relatively
effective treatment method than the other conventional procedures
used. Electro myo-graphic biofeedback (EMGBFB) is a method
which provides feedback regarding the electrical activity of the
muscles and thereby assisting the individual to increase or decrease
the tension developed in the muscle. Since this procedure is not
associated with any of the adverse effects, it is being used for a
longer period in the rehabilitation set up. Various conditions have
been treated with the use of biofeedback devices. Of them, the
effectiveness of EMGBFB has been assessed mostly in knee
conditions in the orthopedic and sports medicine. The effectiveness of
this procedure is evaluated with the use of various measures such as
pain scales, goniometric measurements, isokinetic dynamometric
measurements etc. in literature. Therefore the significance of the
addition of this method in the traditional treatment protocols has
been emphasized. The aim of this study is to review the efficacy of the
EMGBFB interventions in various knee conditions, in the
rehabilitation setting.
Keywords— Biofeedback, EMG, Conventional procedures, Knee
rehabilitation.
I. INTRODUCTION
The term ‗feedback‘ can be defined as ―sensory information
that results from various movements‖ [1]. This feedback can
be either augmented (extrinsic) or sensory (intrinsic) [1, 2].
The information provided from various sensory receptors such
as proprioceptors, auditory and visual receptors [1, 3] are
considered as intrinsic feedback. Biological information
provided in therapeutic setting is considered as extrinsic
feedback where the patient is provided with supplementary
information beyond what is naturally available to them [1-5].
Biofeedback is a procedure which measures an
individual‘s particular body functions such as heart rate, blood
pressure, skin temperature, activity of the brain waves, sweat
gland activity, muscle tension etc. [6] and transfer this
biological information to the individual in real time [7]. This
process allows the subject to regulate these physiological
processes in a conscious manner which are considered as
automatic responses of the autonomic nervous system [6].
Electro myo-graphic biofeedback (EMGBFB) is a process
which helps an individual to identify and magnify the
electrical activity of the muscle. Patient is provided with
visual and auditory feedbacks regarding the tension developed
in the muscle [8]. Biofeedback therapy has been used for more
than fifty years to assist normal movement patterns after an
injury [9].
A typical biofeedback device consists of three main parts;
physiological parameter sensor, signal processing and
biofeedback alogrithm software and audio or visual interface
to the user [6]. However, later it was developed into an
advanced form where the subject is exercising in a computer
generated reality environment [7]. In this case, patient is
provided with graphical or audiovisual animations that enables
the patient to experience a real situation [10].
This tool is used in various therapeutic interventions in the
rehabilitation set up. Biofeedback treatment method is very
popular among the patients since it does not have any side
effects and is safe to use [6]. This process has been used
therapeutically in tension headache [11-14], recovery of motor
function after stroke [15], fibromyalgia syndrome (16- 19],
Temporo-mandibular disorders [20, 21] facial paralysis [22,
23], fecal incontinence [24], urinary incontinence [25-29] and
constipation [30, 31].
Most of the studies have focused on the biofeedback
therapeutic interventions in treating various upper and lower
limb motor deficits which results from neurological disorders
[7]. In orthopedic and sports medicine, the effectiveness of
EMGBFB therapy has been investigated more on knee
conditions [8]. Therefore the aim of this review is to focus on
the effectiveness of EMGBFB therapy on various knee
conditions.
A. Knee Osteoarthritis
Osteoarthritis is known to be the most prevalent joint
disorder in elderly persons [32, 33]. Even though it mainly
affects the joint articular cartilage, the joint capsule,
surrounding ligaments, synovial membrane and subchondral
bone also can be affected [34]. Knee osteoarthritis is most
commonly associated with pain and muscular weakness [35].
It is indicated that the Quadriceps muscle weakness is due to
disuse atrophy which is caused by pain in the joint [36].
Moreover, the advancement of the disease is associated with
the improper knee joint loading [37] and therefore several gait
modifications have been introduced to the patients with the
assistance of movement biofeedback in order to decrease the
load on the affected knee joint [38].
Other than the gait modifications, the effect of EMGBFB
therapy on muscular strength and pain also has been assessed
in literature. A study had been done by Anwer et al., (2011) in
order to evaluate the effectiveness of EMGBFBB along with
isometric quadriceps strengthening exercises in 30 patients
International Research Journal of Advanced Engineering and Science
ISSN (Online): 2455-9024
48
N.D.P.U. Nakandala, ―EMG-Biofeedback Therapy in Knee Rehabilitation: A Review,‖ International Research Journal of Advanced
Engineering and Science, Volume 4, Issue 3, pp. 47-52, 2019.
with knee osteoarthritis [36]. Intervention group had received
EMGBFB guided isometric exercises for five days per week
for five weeks. The control group had received only the
exercises. Quadriceps strength had been measured with an
electronic strain gauge device before the treatment, second,
third and fifth weeks respectively. Strength was measured with
the knee in 60 degree flexion which was found to be having
the greatest torque output. Increased quadriceps strength was
observed in the intervention group.
Choi et al, (2015) had compared the treatment effects of
EMGBFB and Ultrasonic biofeedback (USBF) with
conventional physiotherapy treatment on 30 females
diagnosed with osteoarthritis [39]. Conventional therapy had
included hot pack, TENS and ultrasound treatments where the
intervention groups had received EMGBFB and USBF guided
exercises focusing on vastus medialis oblique muscle (VMO).
Both the intervention groups had significantly improved the
maximum voluntary isometric contraction which was
measured by a strength dynamometer with the knee at 70
degree flexion, VMO thickness was measured by MylabTM
One ultrasound system and the pain was measured by Visual
Analogue Scale (VAS) compared to control group. Study
lacks the long term observation on the patients and therefore
was not able to discuss the long term effects of these methods.
However, a study which was performed to see the effect of
EMGBFB in 40 patients diagnosed with knee osteoarthritis
had shown no significant improvement in pain and muscle
strength in the intervention group when compared with control
group [32]. Intervention group had received EMGBFB with
the exercises where the control group had received only the
exercises. Pain was measured with VAS. Function was
assessed with Western Ontario McMaster Osteoarthritis Index
(WOMAC) and quadriceps strength was measured with a
Cybex isokinetic dynamometer. The treatment procedure had
been continued three times a week for three weeks. The
intervention group had indicated significant improvements
only in sleep and energy scores measured by Nottingham
Health Profile (NHP) but not with pain and muscular strength.
B. Patella-Femoral Pain
Patella femoral pain syndrome (PFPS) can be identified as
a dysfunction where the patella is unable to track in the
trochlear groove properly [40]. It is most commonly found in
young adults [41]. In the general population 10-28% are
affected from this pain syndrome [42] where it represents 25%
of all the knee injuries treated in the sports clinics [43].
Various conservative and surgical approaches have been
introduced to treat this condition [41].
EMGBFB is also one of the conservative approaches
which has been tested on individuals with patella femoral pain
syndrome. Ng et al., (2008) have evaluated the efficacy of
EMGBFB on 26 subjects with PFPS [44]. The intervention
group had received the EMGBFB along with the exercises and
the control group was given only the exercises. EMG ratios of
vastusmedialis (VM) and vastuslateralis (VL); VMO/VL had
been measured with a custom designed portable surface EMG
system for six hours during their normal activities. Twenty
percent maximum EMG was taken as the cut off value which
was found to be achieved by an individual during normal
walking. At the end of eight weeks training session, significant
changes in VMO/VL EMG ratios had been found in the group
who received EMGBFB therapy but no any significant
changes in the exercise only group. Further, they have
concluded the ability to facilitate the VMO activity during
daily activities by combining this EMGBFB approach into
treatment sessions.
EMGBFB coupled with exercises was noted as effective
also by Wise et al., (1984) [40]. During this procedure VMO
activity had been selectively enhanced by anHyperion 31 2
integrated electromyographic biofeedback unit. Three phases
had been introduced to the patient. In phase I, patient was
asked to do pain free isometric quadriceps contractions
without prioritizing any muscle group. In phase II, they were
asked to selectively increase the electrical activity of the VMO
muscle and to keep the VL activity in the base line. In phase
III, They were instructed to in cooperate the increased VMO
activity into functional movement patterns. It had resulted in
changes in patella femoral forces as well as reduction in
patients‘ complains of pain suggesting EMGBFB is an
effective alternative treatment approach to conventional
physiotherapy exercises.
Another study done by Yip & Ng, (2006) had also
evaluated the effectiveness of EMGBFB on PFPS [45].
Twenty six subjects diagnosed with patella femoral pain had
been included in the study. Intervention group only had the
both EMGBFB and the exercises where control group had
only exercises. All had eight weeks home program including
flexibility, strengthening, balance & proprioception training
and plyometric & agility training exercises. Pain level was
assessed by patella femoral pain syndrome severity scale.
Patella alignment had been evaluated by the McConnell test
including patella gliding, tilting and rotation. Isokinetic knee
extension strength had been measured with an isokinetic
dynamometer. The results have indicated an insignificant pain
reduction in both groups, significant reduction in lateral
patella gliding, tilting and rotation in EMGBFB group and
significant improvement in isokinetic peak torque in
EMGBFB group.
Contradictory to these results, a study done by Dursun et
al., (2001) had found no significant clinical improvement with
EMGBFB on PFPS when compared to conventional exercise
sessions [41].
C. Meniscectomy
Meniscal injuries are found to be the most prevalent type
of injuries among athletes where the sports injuries account for
more than 30% of all meniscal lesions [46]. The most common
surgical intervention performed for this meniscal lesions are
the arthroscopic partial meniscectomy [47]. Following
arthroscopic partial meniscectomy, muscle power of the
quadriceps femoris muscle and the activities performed by
knee is known to be impaired [46]. This muscle weakness
occurs as a consequence of reflex inhibition of the motor
neurons [48]. Though surgical approaches are more
pronounced, the need of continuation with rehabilitation
protocols has been widely discussed, and the importance of
International Research Journal of Advanced Engineering and Science
ISSN (Online): 2455-9024
49
N.D.P.U. Nakandala, ―EMG-Biofeedback Therapy in Knee Rehabilitation: A Review,‖ International Research Journal of Advanced
Engineering and Science, Volume 4, Issue 3, pp. 47-52, 2019.
further randomized trials was also emphasized in literature
[49-51]. Anyway, Physiotherapy exercise protocols have been
developed and recommended following meniscetomy injuries
[46]. The use of EMGBFB instrument along with
physiotherapeutic exercises in muscle re-education and muscle
relaxation following meniscectomy surgeries have been also
discussed in literature.
A study done by Akkaya et al., (2011) had recruited 45
patients who had sustained meniscal injuries and have
undergone arthroscopic partial meniscectomy in order to see
the effectiveness of EMGBFB and the electrical stimulation in
addition to the conventional exercises in treating the condition
[52]. Patients had been divided into three groups; first group
had received only the home exercise program, second group
had received EMGBFB to quadriceps muscle and the
exercises where the third group had received the electrical
stimulation to the quadriceps muscle in addition to the
exercises. EMGBFB for isometric quadriceps contraction had
been provided with a Myomed 932 device for five days a
week and for two weeks. Electrical stimulation had been
provided with an Endomed 582 device for a similar time
period. Pain was measured with VAS scale, gait velocity was
assessed by the time taken to walk a 2m distance and function
evaluation was done with a Lysholm Knee Scoring Scale.
Muscle power had been evaluated with the EMGBF device.
They have concluded that the introduction of EMGBFB to
conventional exercise program had speeded up the knee
extensor muscle power recovery and the knee function during
early post-operative period.
A clinical report written by Sprenger et al., (1979) had also
indicated the positive effects of the EMGBFB on vastus
medialis muscle in a patient who had undergone a
meniscectomy surgery [53]. The treatment was given for about
30 minutes daily for seven sessions in addition to the main
stream Physiotherapy exercise program. A feedback
monograph with speaker (BFT Model 401®t) and time-period
integrator (BFT Model 215®|) had been used for both visual
and audio feedback. Patient had been improved with the
vastus medialis muscle control and full knee extension after
four weeks. Similar results had been discussed in a study done
by Kirnap et al., (2005) which was done using 40 patients who
had done arthroscopic meniscectomy [48]. They also have
demonstrated significant differences in knee range of motion,
Lysholm knee score, maximum and average contraction
values of VMO and VL muscles in biofeedback group when
compared with the control group.
D. Anterior Cruciate Ligament Injuries
During last two decades, more studies had been done
regarding the ACL injuries [54]. Literature shows that the
immobilization for a longer period of time following the ACL
reconstruction could be resulted in atrophy of the knee
muscles and adhesion formation [55], decreased knee
extension range of motion (56, 57], impaired strength of the
quadriceps muscle [58, 59] and so on. It has been shown that
the crucial point of the ACL rehabilitation protocols is to
improve the quadriceps femoris muscle function and its force
production [60]. The effectiveness of EMGBFB therapy on
increasing quadriceps muscle function has been evaluated in
literature.
The effectiveness of EMGBFB facilitated exercises and
exercise alone had been evaluated in group of 22 patients who
had undergone ACL reconstruction [55]. Cyborg Model J33
portable biofeedback unit had been used to provide the
EMGBFB. Quadriceps muscle isometric peak torque had been
measured using CybexR II isokinetic dynamometer in 90, 60
and 45 degree angles of knee extension. Significant difference
in peak torque was noted in all the three angles in EMGBFB
group compared to control group thereby concluding, that the
combination of EMGBFB with muscle strengthening exercises
improves the recovery of quadriceps muscle function after
ACL reconstruction.
Both EMGBFB and electrical stimulation have been tested
along with isometric quadriceps exercises in 30 patients with
ACL reconstruction [60]. MyoTracTM EMG biofeedback unit
had been used to monitor the quadriceps femoris activity.
Results have shown that the isometric peak torque of the
quadriceps muscle of the operated limb had been significantly
improved when compared with the adjacent non-operated
limb, in the EMGBF group. CybexR II isokinetic
dynamometer with dual-channel chart recorder had been used
to record the torque.
The most commonly noted complication after this ACL
reconstruction is the failure to achieve the full knee extension
[61]. Christanell et al., (2012) had compared the success of
introducing EMGBFB treatment for vastus medialis muscle in
regaining the knee range of motion and the strength in 16
patients who have undergone endoscopic ACL reconstruction
using patella tendon auto graft [62]. At six weeks post
operatively, significant differences were noted in the
intervention group who received the EMGBFB and standard
rehabilitation protocol both, than the control group that
received only the standard protocol in regaining passive knee
extension. Ultimately they have concluded that addition of
EMGFB therapy to the early phase of rehabilitation after ACL
reconstruction can be resulted in improving the knee range
outcomes. Myotrainer© - Insight Instruments – Austria was
used to provide the BFB therapy. High Heel Distance (HHD)
test was used to measure the passive knee extension.
E. Total Knee Arthroplasty
Total Knee Arthroplasty (TKA) is the standard and most
common surgical approach which is used in the patients with
severe knee osteoarthritis (63-65]. It is known that this
surgical procedure helps in alleviating the pain and associated
problems of knee osteoarthritis [64, 66]. Although this
procedure assists in reduction of pain and the improvement of
the functional outcomes of the individuals, they are left with
muscle strength and functional deficits after years of surgery
[67]. Also it is noted that, unilateral TKA results in decreased
weight bearing and reduced knee extension moments in the
indexed knee and thereby having asymmetrical movement
types in the lower extremities [68, 69]. These asymmetrical
movement patterns during walking, stair climbing and raising
from a chair that favors the non-operated limb could in turn
impose more loads on that limb as well [70, 71]. Therefore,
International Research Journal of Advanced Engineering and Science
ISSN (Online): 2455-9024
50
N.D.P.U. Nakandala, ―EMG-Biofeedback Therapy in Knee Rehabilitation: A Review,‖ International Research Journal of Advanced
Engineering and Science, Volume 4, Issue 3, pp. 47-52, 2019.
the importance of rehabilitation of the individuals after TKR is
emphasized in literature [63)].
A study done by Christiansen et al., (2015) had examined
the effects of weight bearing biofeedback (WB-BFB) training
on reeducation of symmetrical weight bearing and functional
activities such as sit to stand and walking [72]. Twenty six
randomly selected patients who were suggested to undergo
unilateral TKR were divided into two groups and the
intervention group was given the WB-BFB training along with
standard rehabilitation care. Control group had been given
only the standard rehabilitation care. The intervention group
had received BFB training two times a week after the surgery.
Nintendo Wii Fit Plus game and associated Wii Balance Board
had been used for WB biofeedback training. While playing the
game, they had been instructed regarding the correct
movement patterns. Program was started with simple activities
and had progressed into complex activities. They have
concluded that the addition of WB-BFB training had no any
significant effect on the reeducation of weight bearing
symmetry during functional activities on lower extremity.
However, the intervention group had improved the operated
knee extension moment and the functional performance.
A case study has been done by McClelland et al., (2012)
with 57 year old female patient who had undergone unilateral
TKA, in order to see the effectiveness of biofeedback training
on reeducation of symmetrical movement patterns after
surgery [66]. Intervention had been consisted of two main
interventions including progressive strengthening exercises
and BFB training that had induced normal symmetrical
movement patterns in lower limbs. BFB training had included
weight bearing strengthening on the Sym Slide and a leg press
device which was used to observe the force production
through each limb. Movement symmetry was encouraged with
a visual tracing displayed on a video monitor which had
provided visual feedback. Results have concluded that the
patient had improved and restored with the symmetry of the
lower limb movements and correct knee biomechanics after
BFB training.
ZeniJr et al., (2013) also had studied the effect of BFB
training to encourage symmetrical movement patterns in 11
patients who had TKA surgery [64]. A progressive symmetry
restraining program had been introduced which included
visual, tactile and auditory feedback to the patient to induce
kinetic and kinemaic symmetry between limbs. Feedback was
provided with a SymSlide device (customKYnetics, Inc,
Versailles, KY). The results have indicated that symmetry
retraining program have improved the biomechanical
symmetry during functional tasks and also have emphasized
the importance of adding such programs postoperatively rather
than having protocols which focus on range of motion,
strength etc.
Another study had addressed the effect of BFB training on
pain management after TKR surgery [73]. Since the pain
management boosts the patient‘s recovery and avoids long
hospital stay, it is an essential component in rehabilitation set
up [74]. Sixty patients had been randomly selected for the
intervention and control groups. Only the intervention group
had received the BFB assisted progressive muscle relaxation
training simultaneously with the continuous passive motion
(CPM). Pain had been measured using a numeric rating scale.
Biofeedback Nexus-10biofeedback machine (Gunjan Human
Karigar, India) had been used to provide the BFB. Study has
concluded that BFB assisted muscle relaxation is an effective
treatment technique to manage the postoperative pain during
CPM.
II. CONCLUSION
Various studies have been performed in order to evaluate
the effectiveness of EMGBFB therapy on treating various
knee conditions in the rehabilitation set up. Treatment
efficacy has been proved with pain scales, range of motion of
the knee joint, muscle strength, gait velocity, functional levels
etc. Therefore it can be concluded that EMGBFB method is an
effective and non-invasive treatment approach to treat various
knee conditions.
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