Application of Electromyographic Biofeedback Following Medial Meniscectomy A Clinical Report
Key Words: Biofeedback, Electromyographic, Knee, Meniscectomy.
A common complication following medial menis cectomy is a lack of complete knee extension, often despite vigorous rehabilitative efforts. Electromy ographic feedback offers a supplement to traditional physical therapy procedures used to restore complete knee extension following medial meniscectomy. The treatment goal following meniscectomy is to restore full range of motion and strength for knee extension as soon as medically feasible. Often, because of voli tional alienation produced by pain or early fibrosis in tissues around the knee from immobilization, the patient will be incapable of completing the final 15 to 20 degrees of knee extension following meniscectomy. This portion of the range is biomechanically essential for proper gait. The functioning of the vastus medialis muscle appears essential in completing knee extension because it furnishes the medial traction on the patella required in this joint range.1 Neuromuscular reedu cation of the vastus medialis muscle is invariably necessary and advantageous because the more quickly reeducation occurs, the less atrophy of the vastus medialis occurs and the quicker the full recov ery of the patient. The following clinical report demonstrates the pos itive effect of biofeedback of electromyographic activ ity of the vastus medialis muscle in a patient who underwent meniscectomy and who lacked terminal extension of the lower extremity after surgery. His
Ms. Sprenger is currently Staff Physical Therapist, Tucson Medical Center, 5301 East Grant Rd, Tucson, AZ 85712. At the time the manuscript was prepared, Ms. Sprenger was a student at the Univer sity of North Dakota School of Medicine, Grand Forks, ND 58201. Dr. Carlson is a Staff Psychologist, Medical Center Rehabilitation Hospital, Grand Forks, ND 58201. Mr. Wessman is Professor and Chairman, Department of Physical Therapy, University of North Dakota School of Medicine. This article was submitted December 5, 1977, and accepted June 7, 1978.
Volume 59 / Number 2, February 1979
progress is compared to a group of four patients who underwent meniscectomy and who received similar therapeutic programs except for the biofeedback. The patient was a 28-year-old man who sustained a right knee injury in a snowmobile accident six years before the surgery. In April 1977, the patient strained the knee while participating in an athletic activity and was admitted to a hospital. Upon admission, the diagnosis was 1) severely torn meniscus of the right knee, 2) medial and posteromedial instability and rotatory instability of the right knee, and 3) traumatic loss of cartilage on the medial femoral articular con dylar surface of the right knee. After evaluation, an arthrotomy of the anterior medial right knee was performed. Seven weeks after surgery, examination of the right knee revealed medial instability and a severe loss of motion resulting in a range of motion of 35 degrees of extension to 65 degrees of flexion. Edema was also present in the foot and ankle. At that time, the patient was admitted to a rehabilitative facility for an aggres sive physical therapy regimen. The physical therapy program consisted of contrast packs and Jobst®* intermittent positive pressure twice a day to the right lower extremity to reduce edema and postsurgical pain. A series of strengthen ing and stretching exercises was also prescribed to increase function and range of motion in the right lower extremity. Gait training and weight-bearing exercises were to be introduced as tolerated when the patient had improved sufficiently. In addition to the traditional physical therapy, electromyographic biofeedback of the vastus medialis muscle was introduced. The feedback training ses sions were approximately 30 minutes long and came
* Jobst Institute, PO Box 653, Toledo, OH 43694. 167
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
CYNTHIA K. SPRENGER, BS, KENNETH CARLSON, PhD, and HENRY C. WESSMAN, MS
relaxed vastus medialis muscle remained the same throughout treatment. This improvement in control of activity of the vastus medialis muscle was corre lated to changes in the patient's active range of motion of the lower extremity. On admission (seven weeks after surgery), the patient had a range of motion lacking 35 degrees of extension, with 65 degrees of flexion. At discharge, the patient lacked 10 degrees of extension but could flex to 75 degrees. Therefore, the focus of biofeedback treatment, in this case, training the vastus medialis muscle for terminal extension, produced the greatest gain (25° in range of motion) while the patient was in the hospital, as compared to gains of other patients who had had meniscectomies (Table) and who did not have the advantage of biofeedback training. At the time of discharge, the patient was given a portable (Cyborg J33®:}:) electromyographic biofeed back unit and instructed to continue both the program of biofeedback and the physical therapy home pro gram on a daily basis. At follow-up (four weeks after discharge, 11 weeks after surgery), the patient dis played a further gain in the level of activity of the
f Biofeedback Technology Inc, 10592 Trask Ave, Garden Grove, CA | Cyborg Corp, 342 Western Ave, Boston, MA 02135. 92643.
Key: A-A Average relaxation for each session •—• Average contraction for each session 160140120-
100 >
80-| 60^
40 20
_ —-A"
--a-—i—
12
3
4
5
6
7
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
at the end of the patient's therapeutic day. The feed back procedure involved attaching three adhesive silver-silver chloride electrodes parallel to the distal fibers of the patient's vastus medialis muscle. A feed back monograph with speaker (BFT Model 401®t) and time-period integrator (BFT Model 215®|) al lowed for both visual and audio feedback and pro vided the opportunity for quantifying the patient's response. When prepared, the patient was asked to tighten the right vastus medialis muscle, concentrat ing on the medial aspect of the thigh, for 10 seconds. The patient was then told to relax the entire lower extremity for 20 seconds. This procedure was repeated for approximately 20 minutes or until biofeedback recordings indicated muscle fatigue. The patient was seen daily for seven sessions of biofeedback. During the weekend between the third and fourth sessions, the patient received physical therapy without biofeedback. Results of the biofeed back sessions are shown in the Figure. There was a steady improvement in control of muscle activity during the seven sessions. Activity detected in the
-A
Follow-up (4 weeks)
DAY OF THERAPY Figure. Muscle activity during seven daily biofeedback sessions and at follow-up.
168
PHYSICAL THERAPY
TABLE Comparable Data on Patients Who Underwent Meniscectomy Age
Rehabilita tion Stay
Range of Motion on Admission Extension
Flexion
Range of Motion on Net Gain in Follow-up Data Discharge Extension During Re Extension Flexion habilitation Extension Flexion Stay
50
7 days
10°
118°
10°
120°
0°
2
52
10 days
14°
75°
10°
105°
4°
3
18
11 days
40°
25°
115°
15°
4
25
11 days
18°
60°
5°
95°
13°
At 15 weeks: 0° 125° At 25 weeks: 0° 135° At 40 weeks: 0° 130° At 10 weeks: 0° 135°
28
10 days
65 c
10°
75 c
25°
0°
Case Study Patient
At 4 weeks:
vastus medialis muscle. The follow-up showed normal leg extension (0°) and knee flexion of 100 degrees. He was walking normally without any assistive de vices and had returned to work. In order to fully understand the impact of biofeed back as a therapeutic adjunct in cases of medial meniscectomy, results of this case were compared to results of four individuals who had a similar surgery and had been admitted to the same facility in the 18 months prior to the case study (Table). The physical therapy for all individuals was comparable except for this study patient where biofeedback was used. As can be seen in the Table, the patient receiving bio feedback made the most significant net gain in exten sion as an inpatient. At a four-week follow-up, the patient had obtained full knee extension. Similar
Volume 59 / Number 2, February 1979
100°
improvements had taken comparable patients longer to achieve. An obvious advantage of using electromyographic biofeedback during treatment is that the audio feed back seems to increase patient motivation. The pa tient also gets immediate positive reinforcement from both the audio and microvolt recordings, and these serve as a basis for comparing the response of future biofeedback sessions. The results in this report provide support for the usefulness of biofeedback training as an adjunct to physical therapy in treating a patient following medial meniscectomy. REFERENCE 1. Brunnstrom S: Clinical Kinesiology, ed 3. Philadelphia, F. A. Davis Co, 1972, pp 194-195
169
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
1
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Patient
Key Words: Biofeedback, Electromyographic, Knee, Meniscectomy.
A common complication following medial menis cectomy is a lack of complete knee extension, often despite vigorous rehabilitative efforts. Electromy ographic feedback offers a supplement to traditional physical therapy procedures used to restore complete knee extension following medial meniscectomy. The treatment goal following meniscectomy is to restore full range of motion and strength for knee extension as soon as medically feasible. Often, because of voli tional alienation produced by pain or early fibrosis in tissues around the knee from immobilization, the patient will be incapable of completing the final 15 to 20 degrees of knee extension following meniscectomy. This portion of the range is biomechanically essential for proper gait. The functioning of the vastus medialis muscle appears essential in completing knee extension because it furnishes the medial traction on the patella required in this joint range.1 Neuromuscular reedu cation of the vastus medialis muscle is invariably necessary and advantageous because the more quickly reeducation occurs, the less atrophy of the vastus medialis occurs and the quicker the full recov ery of the patient. The following clinical report demonstrates the pos itive effect of biofeedback of electromyographic activ ity of the vastus medialis muscle in a patient who underwent meniscectomy and who lacked terminal extension of the lower extremity after surgery. His
Ms. Sprenger is currently Staff Physical Therapist, Tucson Medical Center, 5301 East Grant Rd, Tucson, AZ 85712. At the time the manuscript was prepared, Ms. Sprenger was a student at the Univer sity of North Dakota School of Medicine, Grand Forks, ND 58201. Dr. Carlson is a Staff Psychologist, Medical Center Rehabilitation Hospital, Grand Forks, ND 58201. Mr. Wessman is Professor and Chairman, Department of Physical Therapy, University of North Dakota School of Medicine. This article was submitted December 5, 1977, and accepted June 7, 1978.
Volume 59 / Number 2, February 1979
progress is compared to a group of four patients who underwent meniscectomy and who received similar therapeutic programs except for the biofeedback. The patient was a 28-year-old man who sustained a right knee injury in a snowmobile accident six years before the surgery. In April 1977, the patient strained the knee while participating in an athletic activity and was admitted to a hospital. Upon admission, the diagnosis was 1) severely torn meniscus of the right knee, 2) medial and posteromedial instability and rotatory instability of the right knee, and 3) traumatic loss of cartilage on the medial femoral articular con dylar surface of the right knee. After evaluation, an arthrotomy of the anterior medial right knee was performed. Seven weeks after surgery, examination of the right knee revealed medial instability and a severe loss of motion resulting in a range of motion of 35 degrees of extension to 65 degrees of flexion. Edema was also present in the foot and ankle. At that time, the patient was admitted to a rehabilitative facility for an aggres sive physical therapy regimen. The physical therapy program consisted of contrast packs and Jobst®* intermittent positive pressure twice a day to the right lower extremity to reduce edema and postsurgical pain. A series of strengthen ing and stretching exercises was also prescribed to increase function and range of motion in the right lower extremity. Gait training and weight-bearing exercises were to be introduced as tolerated when the patient had improved sufficiently. In addition to the traditional physical therapy, electromyographic biofeedback of the vastus medialis muscle was introduced. The feedback training ses sions were approximately 30 minutes long and came
* Jobst Institute, PO Box 653, Toledo, OH 43694. 167
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
CYNTHIA K. SPRENGER, BS, KENNETH CARLSON, PhD, and HENRY C. WESSMAN, MS
relaxed vastus medialis muscle remained the same throughout treatment. This improvement in control of activity of the vastus medialis muscle was corre lated to changes in the patient's active range of motion of the lower extremity. On admission (seven weeks after surgery), the patient had a range of motion lacking 35 degrees of extension, with 65 degrees of flexion. At discharge, the patient lacked 10 degrees of extension but could flex to 75 degrees. Therefore, the focus of biofeedback treatment, in this case, training the vastus medialis muscle for terminal extension, produced the greatest gain (25° in range of motion) while the patient was in the hospital, as compared to gains of other patients who had had meniscectomies (Table) and who did not have the advantage of biofeedback training. At the time of discharge, the patient was given a portable (Cyborg J33®:}:) electromyographic biofeed back unit and instructed to continue both the program of biofeedback and the physical therapy home pro gram on a daily basis. At follow-up (four weeks after discharge, 11 weeks after surgery), the patient dis played a further gain in the level of activity of the
f Biofeedback Technology Inc, 10592 Trask Ave, Garden Grove, CA | Cyborg Corp, 342 Western Ave, Boston, MA 02135. 92643.
Key: A-A Average relaxation for each session •—• Average contraction for each session 160140120-
100 >
80-| 60^
40 20
_ —-A"
--a-—i—
12
3
4
5
6
7
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
at the end of the patient's therapeutic day. The feed back procedure involved attaching three adhesive silver-silver chloride electrodes parallel to the distal fibers of the patient's vastus medialis muscle. A feed back monograph with speaker (BFT Model 401®t) and time-period integrator (BFT Model 215®|) al lowed for both visual and audio feedback and pro vided the opportunity for quantifying the patient's response. When prepared, the patient was asked to tighten the right vastus medialis muscle, concentrat ing on the medial aspect of the thigh, for 10 seconds. The patient was then told to relax the entire lower extremity for 20 seconds. This procedure was repeated for approximately 20 minutes or until biofeedback recordings indicated muscle fatigue. The patient was seen daily for seven sessions of biofeedback. During the weekend between the third and fourth sessions, the patient received physical therapy without biofeedback. Results of the biofeed back sessions are shown in the Figure. There was a steady improvement in control of muscle activity during the seven sessions. Activity detected in the
-A
Follow-up (4 weeks)
DAY OF THERAPY Figure. Muscle activity during seven daily biofeedback sessions and at follow-up.
168
PHYSICAL THERAPY
TABLE Comparable Data on Patients Who Underwent Meniscectomy Age
Rehabilita tion Stay
Range of Motion on Admission Extension
Flexion
Range of Motion on Net Gain in Follow-up Data Discharge Extension During Re Extension Flexion habilitation Extension Flexion Stay
50
7 days
10°
118°
10°
120°
0°
2
52
10 days
14°
75°
10°
105°
4°
3
18
11 days
40°
25°
115°
15°
4
25
11 days
18°
60°
5°
95°
13°
At 15 weeks: 0° 125° At 25 weeks: 0° 135° At 40 weeks: 0° 130° At 10 weeks: 0° 135°
28
10 days
65 c
10°
75 c
25°
0°
Case Study Patient
At 4 weeks:
vastus medialis muscle. The follow-up showed normal leg extension (0°) and knee flexion of 100 degrees. He was walking normally without any assistive de vices and had returned to work. In order to fully understand the impact of biofeed back as a therapeutic adjunct in cases of medial meniscectomy, results of this case were compared to results of four individuals who had a similar surgery and had been admitted to the same facility in the 18 months prior to the case study (Table). The physical therapy for all individuals was comparable except for this study patient where biofeedback was used. As can be seen in the Table, the patient receiving bio feedback made the most significant net gain in exten sion as an inpatient. At a four-week follow-up, the patient had obtained full knee extension. Similar
Volume 59 / Number 2, February 1979
100°
improvements had taken comparable patients longer to achieve. An obvious advantage of using electromyographic biofeedback during treatment is that the audio feed back seems to increase patient motivation. The pa tient also gets immediate positive reinforcement from both the audio and microvolt recordings, and these serve as a basis for comparing the response of future biofeedback sessions. The results in this report provide support for the usefulness of biofeedback training as an adjunct to physical therapy in treating a patient following medial meniscectomy. REFERENCE 1. Brunnstrom S: Clinical Kinesiology, ed 3. Philadelphia, F. A. Davis Co, 1972, pp 194-195
169
Downloaded from https://academic.oup.com/ptj/article-abstract/59/2/167/4559475 by guest on 08 October 2018
1
OO oo
Patient
