Electromyographic Feedback to Improve Ankle Dorsiflexion, Wrist Extension, and Hand Grasp HARRY NAFPLIOTIS, MA
Electromyographic feedback was used to train a patient with hemiplegia in the functional use of the muscles of his right upper and lower limbs. The patient trained with the therapist over a period of two and one-half months, engaging in exercises for ankle dorsiflexion, wrist extension, and hand grasp twice a week for one to one and one-half hours. Feedback was recorded with surface elec trodes placed over the extensor surface of the forearm and the tibialis anterior; the electromyographic activity was displayed on a meter. After training, muscle control proved functional for walking, handwriting, and daily self-care activities.
^^ecent studies and therapeutic suc cesses have shown that biofeedback tech niques, accompanied by appropriate motiva tion and instruction, can often enable a pa tient to obtain a remarkable degree of strength in previously dysfunctioning muscle groups in a relatively short period of train ing. 1 - 1 3 Studies have also shown that biofeed back can give a patient an extraordinary de gree of voluntary control over physiological activities previously considered involuntary, reflexive, or subconscious. 3 , 12 Biofeedback training involves the transla tion of the physiological activity of a particu lar response of the patient into the electrical signals of a visual or auditory system. With an electromyographic feedback system, a pa tient may monitor his muscular activity. Such feedback, combined with normal kinesthetic, proprioceptive, and visual sensory input, can Mr. Nafpliotis is director, Physical Therapy Center of Teaneck, 175 Cedar Lane, Teaneck, NJ 07666. This article was adapted from a paper presented at the Annual Conference of the American Physical Therapy As sociation, Anaheim, CA, June 19, 1975.
Volume 56 / Number
7, July
1976
aid the subject's effort to improve control over specific muscle groups, whether the goal is facilitation or inhibition of the muscle activity involved. Johnson and Garton have reported success in reeducation of both upper and lower limbs in cases of hemiplegia when traditional physi cal and occupational therapy did not prove successful. 1 1 Basmajian and Kukulka have re ported similar success in the treatment of foot-drop in hemiplegic patients. 4 Amato and colleagues, on the other hand, have used electromyographic feedback to increase in hibitory control of spastic muscles. 1 Segal, in a recent study, emphasized that biofeedback techniques simply rationalize and, thereby, accelerate the learning proc ess. 10 Biofeedback is a training procedure. It allows the patient to do things for himself. The following case of successful biofeed back therapy is of interest in that a discour aged patient, who had been unable to over come a severe hemiparetic condition under other treatment procedures, gained new mo tivation during his first experience with the
821
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
case repoit
biofeedback technique and thereafter made steady and rapid progress. The patient was a 61-year-old white man. He was cooperative and, in general, moti vated to improve his physiological responses, but he was extremely skeptical regarding the potential effectiveness of the electromy ographic feedback technique. Approximately five months before biofeed back training, he had suffered a cerebrovas cular accident resulting in right hemiplegia and mild aphasia. He had had a long-standing history of diabetes. The patient had undergone several months of traditional physical therapy which included passive range of motion, active assistive ex ercise, progressive resistive exercise, gait training, and transfer training. He stated that he had improved considerably but had reached a plateau, beyond which he seemed unable to progress. Residual muscle function loss remained in both right upper and right lower limbs. Initial evaluation revealed normal passive range of motion, with the exception of ankle dorsiflexion which was limited to 10 degrees. Both position sense and body orientation were good; both touch and texture sensation were normal. Proximal muscles were less affected than distal muscles. The patient was able to flex and abduct the shoulder to 70 degrees. He was able to flex the elbow fully. Finger motion (hand-grasp) was incomplete. In the right lower limb, the hip could be flexed actively 45 degrees from the sitting position and could
822
TRAINING The electromyographic feedback was pro vided by an electromyographic feedback monitor* which responds to signals of 0 to 1200 Hz. Signals are collected, amplified, and averaged, then converted to a visual meter display and a variable frequency audio tone. The meter was subject to a threshold control device, such that manual adjustment would lead to a greater or lesser amplitude of de flection (multiplied feedback, for example) for the same muscular effort. Because pitch alteration in the audio system was not subject to similar threshold control, its use was dis continued after the initial training session. The continuous visual feedback provided at the desired threshold level by the meter was the primary tool in the training. During the initial training session, the na ture of the patient's muscular dysfunction and the nature of the feedback device were explained to him. Three surface electrodes measuring 1.3 cm in diameter —one serving as a ground electrode —were placed over the surface area of the right forearm extensors (the bellies approximated by comparison with the normal left forearm). The patient was able to observe the meter's deflection and hear the rise in tone-pitch as he contracted and re laxed the muscle repeatedly (Fig. 1). The pa tient understood that the range of meter de flection during activity was a measure of his * MR 260 Feedback Monitor, Bio-Dyne Corp, 161 E Erie, Chicago, IL 60611.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
Fig. 7. Three stainless steel electrodes, 1.3 cm in diameter, applied to the forearm extensor muscles.
be abducted 15 degrees in a side-lying posi tion; the right knee could be actively flexed to 90 degrees and extended fully. No dorsiflex ion was evident in the right ankle: the tibialis anterior and the peroneus tertius displayed no active movement. The patient had an abducted, hemiparetic gait. The right foot inverted and plantar flexed at toe-off and the hip partially ab ducted. Knee flexion was minimal. At heelstrike, the foot often contacted the floor at the lateral border of the sole in a drop-foot gait, which made a short leg brace necessary. The left arm was held in abduction with about 30 degrees of elbow flexion; the hand was pronated and the wrist flexed.
Volume 56 / Number 7, July 1976
performance had improved sufficiently to permit the therapist to raise the feedback threshold 100 percent. Thereafter, the thera pist checked and recorded the meter reading and threshold level after every 15 mintes of each type of exercise, increasing the thresh old when performance warranted. The patient attended 20 training sessions during two and one-half months, exercising an average of twice a week in the presence of the therapist. The length of each session var ied from one to one and one-half hours, of which 30 to 45 minutes were spent on upper limb exercises, followed by 30 to 45 minutes of lower limb exercise. (Because of the pa tient's diabetic history, blood pressure read ings were taken both before and after each complete training session.) By the fourth training session, in addition to observing the electromyographic feedback as before, the patient was able to observe both his ankle dorsiflexion and wrist exten sion directly. This improvement provided new encouragement for his efforts. By the sixth session, the patient's ability to extend his wrist had improved to such an extent that hand-grasp and finger-motion ex ercises were begun. The electrodes were maintained in the same position over the forearm extensors, and the patient was in structed to "form a fist" repeatedly with his arms fully extended in front of him, observing the meter deflection as in the previous wristextension exercise. He was informed that the response potential of the same muscle group was being monitored, despite the change in exercise. With the exception of the low initial thresh old level, which was superseded within the first session, each higher feedback threshold level was maintained as appropriate for the exercises over the course of three to four sessions. The patient's progress followed the pattern of achieving a plateau, improving upon it little by little over a period of one and one-half to two weeks, and then advancing to the next plateau of muscular strength and control, as measured by the threshold level. Had the threshold control been placed at a higher level any sooner than his muscular improvement warranted, the sudden sharp reduction in feedback might have disoriented
823
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
ability to extend his wrist normally. He was told that this wrist extension exercise was preparatory to finger motion exercise for an improved hand grasp. Improved hand grasp was considered essential to improved hand writing ability, a primary goal of the patient. A similar procedure of introduction was un dertaken for the patient's ankle dorsiflexion disorder. The same electrodes were placed over the belly of the tibialis anterior (again, approximated by comparison with the normal left tibialis anterior). After observing meter deflection during repeated contraction and relaxation of the muscle, the patient quickly understood that the meter's response was a measure of his muscular performance. The dorsiflexion exercise was performed while the patient was supine with the knee straight. Sand bags were used to maintain the ankle in a neutral position so that misleading feedback from plantar flexion would not oc cur. In performing wrist extension and ankle dorsiflexion exercises, the patient was in structed to try to learn what the respective muscles "feel" like when contracted and re laxed. During the initial treatment evaluation ses sion, the patient's skepticism about the feed back technique was overcome. He grew ex tremely excited when he first attempted each exercise movement and received feedback. He was told to "try to move the needle on the meter as close to 1.0 as possible," that is, he was to try to dorsiflex the ankle, or extend the wrist, as much as possible. At the beginning of training, the threshold control of the feedback device was set so that little electromyographic activity was required to cause the meter to deflect. As training pro gressed, whenever both the patient and ther apist were satisfied that his skill in ankle dor siflexion and wrist extension had sufficiently improved, the threshold device was adjusted upward so that a greater muscular response was required to elicit the same meter deflec tion. In short, whenever the feedback thresh old level was increased, the patient had to demonstrate correspondingly improved ca pacities for ankle dorsiflexion and wrist ex tension. By the end of the first session, the patient's
/AA"
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4//?t o •
^
^
,
d
^
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ijt>'( A'""'/ 4(/fc,,>l.t
CUS€- . fix ffff-
I(rt&f0
-365" '~yT)&zcr>'c.3_jJ~>^ OA^_
^ r r - -v-f/>•
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Fig. 2. Patient's initial writing ability after several sessions of training. (Name and address are ficti tious.)
Fig. 3. Patient's progress in writing ability after two months of training. (Name and address are fictitious.)
the patient. Only when the patient had ob tained maximum or near-maximum feedback levels for a given threshold level was the level changed.
Acknowledgment. The author is indebted to Marilyn Wurtzel, MD, for her invaluable assistance in this clinical investigation. REFERENCES
RESULTS After two and one-half months of training, or 20 complete exercise sessions, the active range of motion in the right ankle equaled passive range of motion, and the short leg brace was no longer necessary. No isolated inversion or eversion was observed. Muscle action in ankle dorsiflexion now permitted a functional gait. Wrist extension had undergone similar im provement, and hand-grasp, negligible be fore therapy, was approximately 30 to 50 per cent (45 kg by hand dynamometer) of a nor mal individual's. The resulting improvement in the patient's handwriting ability is shown in Figures 2 and 3. 824
1. Amato A, Hermsmeyer C, Kleinman K: Use of electro myographic feedback to increase inhibitory control of spastic muscles. Phys Ther 53:1063-1066, 1973 2. Andrews J: Neuromuscular re-education of the hemiplegic with the aid of the electromyograph. Arch Phys Med Rehabil 45:530-532, 1964 3. Barber T (ed): Biofeedback and Self-Control. Chicago, Aldine-Atherton, 1971 4. Basmajian J, Kukulka C: Biofeedback treatment of foot-drop after stroke compared with standard reha bilitation technique. Arch Phys Med Rehabil 56:231233,1975 5. Black J, Lagerson J, Zohman L: A feedback device for teaching diaphragmatic breathing. Am Rev Respir Dis 100:335-348, 1969 6. Booker H, Rubrow R, Coleman P: Simplified feedback in neuromuscular retraining: An automated approach using electromyographic signals. Arch Phys Med Re habil 50:621-625, 1969 7. Brudny J, Grynbaum BL, Koreim J: Spasmodic Torti collis: Treatment by feedback display of EMG. Arch Phys Med Rehabil 55:403-408, 1974
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
nlirlr?
plegia by use of electromyographic device. Arch Phys Med Rehabil 54:320-322, 1973 12. Karlins M, Andrews L: Biofeedback: Turning On the Power of Your Mind. Philadelphia, J. B. Lippincott Co, 1972 13. Weiss T, Engel B: Operant conditioning of heart rate in patients with premature ventricular contractions. Psychosom Med 33:301-321, 1971
Now! One Source for All Burn Articles ,
-WIS*-'"
Now available in a single volume—all arti cles on burns which have been published in PHYSICAL THERAPY. Eighteen articles. A Paper, 73 pp, ilius, $4.00
wealth of information from a forty-year span of material. A handy reference source for the physical therapy practitioner.
Prepayment is required on all orders—price is subject to change without notice. Allow three weeks for delivery. All orders are sent postage paid. Make checks payable to:
American Physical Therapy Association 1156 15th St., N.W., Washington, D.C. 20005
Volume 56 / Number 7, July 1976
825
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
8. Brudny J: Sensory feedback therapy as a modality of treatment in CNS disorders of voluntary movement. Neurology 10:925-932, 1974 9. Budzynski T, Stoyva J, Adler C: Feedback-induced muscle relaxation: Application to tension headache. J. Behav Ther Exp Psychiatr 1:205-211, 1970. 10. Segal J: Biofeedback as a medical treatment. JAMA 232:179-180, 1975 11. Johnson H, Garton W: Muscle re-education in hemi
Electromyographic feedback was used to train a patient with hemiplegia in the functional use of the muscles of his right upper and lower limbs. The patient trained with the therapist over a period of two and one-half months, engaging in exercises for ankle dorsiflexion, wrist extension, and hand grasp twice a week for one to one and one-half hours. Feedback was recorded with surface elec trodes placed over the extensor surface of the forearm and the tibialis anterior; the electromyographic activity was displayed on a meter. After training, muscle control proved functional for walking, handwriting, and daily self-care activities.
^^ecent studies and therapeutic suc cesses have shown that biofeedback tech niques, accompanied by appropriate motiva tion and instruction, can often enable a pa tient to obtain a remarkable degree of strength in previously dysfunctioning muscle groups in a relatively short period of train ing. 1 - 1 3 Studies have also shown that biofeed back can give a patient an extraordinary de gree of voluntary control over physiological activities previously considered involuntary, reflexive, or subconscious. 3 , 12 Biofeedback training involves the transla tion of the physiological activity of a particu lar response of the patient into the electrical signals of a visual or auditory system. With an electromyographic feedback system, a pa tient may monitor his muscular activity. Such feedback, combined with normal kinesthetic, proprioceptive, and visual sensory input, can Mr. Nafpliotis is director, Physical Therapy Center of Teaneck, 175 Cedar Lane, Teaneck, NJ 07666. This article was adapted from a paper presented at the Annual Conference of the American Physical Therapy As sociation, Anaheim, CA, June 19, 1975.
Volume 56 / Number
7, July
1976
aid the subject's effort to improve control over specific muscle groups, whether the goal is facilitation or inhibition of the muscle activity involved. Johnson and Garton have reported success in reeducation of both upper and lower limbs in cases of hemiplegia when traditional physi cal and occupational therapy did not prove successful. 1 1 Basmajian and Kukulka have re ported similar success in the treatment of foot-drop in hemiplegic patients. 4 Amato and colleagues, on the other hand, have used electromyographic feedback to increase in hibitory control of spastic muscles. 1 Segal, in a recent study, emphasized that biofeedback techniques simply rationalize and, thereby, accelerate the learning proc ess. 10 Biofeedback is a training procedure. It allows the patient to do things for himself. The following case of successful biofeed back therapy is of interest in that a discour aged patient, who had been unable to over come a severe hemiparetic condition under other treatment procedures, gained new mo tivation during his first experience with the
821
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
case repoit
biofeedback technique and thereafter made steady and rapid progress. The patient was a 61-year-old white man. He was cooperative and, in general, moti vated to improve his physiological responses, but he was extremely skeptical regarding the potential effectiveness of the electromy ographic feedback technique. Approximately five months before biofeed back training, he had suffered a cerebrovas cular accident resulting in right hemiplegia and mild aphasia. He had had a long-standing history of diabetes. The patient had undergone several months of traditional physical therapy which included passive range of motion, active assistive ex ercise, progressive resistive exercise, gait training, and transfer training. He stated that he had improved considerably but had reached a plateau, beyond which he seemed unable to progress. Residual muscle function loss remained in both right upper and right lower limbs. Initial evaluation revealed normal passive range of motion, with the exception of ankle dorsiflexion which was limited to 10 degrees. Both position sense and body orientation were good; both touch and texture sensation were normal. Proximal muscles were less affected than distal muscles. The patient was able to flex and abduct the shoulder to 70 degrees. He was able to flex the elbow fully. Finger motion (hand-grasp) was incomplete. In the right lower limb, the hip could be flexed actively 45 degrees from the sitting position and could
822
TRAINING The electromyographic feedback was pro vided by an electromyographic feedback monitor* which responds to signals of 0 to 1200 Hz. Signals are collected, amplified, and averaged, then converted to a visual meter display and a variable frequency audio tone. The meter was subject to a threshold control device, such that manual adjustment would lead to a greater or lesser amplitude of de flection (multiplied feedback, for example) for the same muscular effort. Because pitch alteration in the audio system was not subject to similar threshold control, its use was dis continued after the initial training session. The continuous visual feedback provided at the desired threshold level by the meter was the primary tool in the training. During the initial training session, the na ture of the patient's muscular dysfunction and the nature of the feedback device were explained to him. Three surface electrodes measuring 1.3 cm in diameter —one serving as a ground electrode —were placed over the surface area of the right forearm extensors (the bellies approximated by comparison with the normal left forearm). The patient was able to observe the meter's deflection and hear the rise in tone-pitch as he contracted and re laxed the muscle repeatedly (Fig. 1). The pa tient understood that the range of meter de flection during activity was a measure of his * MR 260 Feedback Monitor, Bio-Dyne Corp, 161 E Erie, Chicago, IL 60611.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
Fig. 7. Three stainless steel electrodes, 1.3 cm in diameter, applied to the forearm extensor muscles.
be abducted 15 degrees in a side-lying posi tion; the right knee could be actively flexed to 90 degrees and extended fully. No dorsiflex ion was evident in the right ankle: the tibialis anterior and the peroneus tertius displayed no active movement. The patient had an abducted, hemiparetic gait. The right foot inverted and plantar flexed at toe-off and the hip partially ab ducted. Knee flexion was minimal. At heelstrike, the foot often contacted the floor at the lateral border of the sole in a drop-foot gait, which made a short leg brace necessary. The left arm was held in abduction with about 30 degrees of elbow flexion; the hand was pronated and the wrist flexed.
Volume 56 / Number 7, July 1976
performance had improved sufficiently to permit the therapist to raise the feedback threshold 100 percent. Thereafter, the thera pist checked and recorded the meter reading and threshold level after every 15 mintes of each type of exercise, increasing the thresh old when performance warranted. The patient attended 20 training sessions during two and one-half months, exercising an average of twice a week in the presence of the therapist. The length of each session var ied from one to one and one-half hours, of which 30 to 45 minutes were spent on upper limb exercises, followed by 30 to 45 minutes of lower limb exercise. (Because of the pa tient's diabetic history, blood pressure read ings were taken both before and after each complete training session.) By the fourth training session, in addition to observing the electromyographic feedback as before, the patient was able to observe both his ankle dorsiflexion and wrist exten sion directly. This improvement provided new encouragement for his efforts. By the sixth session, the patient's ability to extend his wrist had improved to such an extent that hand-grasp and finger-motion ex ercises were begun. The electrodes were maintained in the same position over the forearm extensors, and the patient was in structed to "form a fist" repeatedly with his arms fully extended in front of him, observing the meter deflection as in the previous wristextension exercise. He was informed that the response potential of the same muscle group was being monitored, despite the change in exercise. With the exception of the low initial thresh old level, which was superseded within the first session, each higher feedback threshold level was maintained as appropriate for the exercises over the course of three to four sessions. The patient's progress followed the pattern of achieving a plateau, improving upon it little by little over a period of one and one-half to two weeks, and then advancing to the next plateau of muscular strength and control, as measured by the threshold level. Had the threshold control been placed at a higher level any sooner than his muscular improvement warranted, the sudden sharp reduction in feedback might have disoriented
823
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
ability to extend his wrist normally. He was told that this wrist extension exercise was preparatory to finger motion exercise for an improved hand grasp. Improved hand grasp was considered essential to improved hand writing ability, a primary goal of the patient. A similar procedure of introduction was un dertaken for the patient's ankle dorsiflexion disorder. The same electrodes were placed over the belly of the tibialis anterior (again, approximated by comparison with the normal left tibialis anterior). After observing meter deflection during repeated contraction and relaxation of the muscle, the patient quickly understood that the meter's response was a measure of his muscular performance. The dorsiflexion exercise was performed while the patient was supine with the knee straight. Sand bags were used to maintain the ankle in a neutral position so that misleading feedback from plantar flexion would not oc cur. In performing wrist extension and ankle dorsiflexion exercises, the patient was in structed to try to learn what the respective muscles "feel" like when contracted and re laxed. During the initial treatment evaluation ses sion, the patient's skepticism about the feed back technique was overcome. He grew ex tremely excited when he first attempted each exercise movement and received feedback. He was told to "try to move the needle on the meter as close to 1.0 as possible," that is, he was to try to dorsiflex the ankle, or extend the wrist, as much as possible. At the beginning of training, the threshold control of the feedback device was set so that little electromyographic activity was required to cause the meter to deflect. As training pro gressed, whenever both the patient and ther apist were satisfied that his skill in ankle dor siflexion and wrist extension had sufficiently improved, the threshold device was adjusted upward so that a greater muscular response was required to elicit the same meter deflec tion. In short, whenever the feedback thresh old level was increased, the patient had to demonstrate correspondingly improved ca pacities for ankle dorsiflexion and wrist ex tension. By the end of the first session, the patient's
/AA"
A.i *S~
h j if 0 3x
4//?t o •
^
^
,
d
^
"i-t->-v-) rfis-s
P:\ou( • ^ _J>^
^jenQZ-
ijt>'( A'""'/ 4(/fc,,>l.t
CUS€- . fix ffff-
I(rt&f0
-365" '~yT)&zcr>'c.3_jJ~>^ OA^_
^ r r - -v-f/>•
5T? 3 ? q i
Fig. 2. Patient's initial writing ability after several sessions of training. (Name and address are ficti tious.)
Fig. 3. Patient's progress in writing ability after two months of training. (Name and address are fictitious.)
the patient. Only when the patient had ob tained maximum or near-maximum feedback levels for a given threshold level was the level changed.
Acknowledgment. The author is indebted to Marilyn Wurtzel, MD, for her invaluable assistance in this clinical investigation. REFERENCES
RESULTS After two and one-half months of training, or 20 complete exercise sessions, the active range of motion in the right ankle equaled passive range of motion, and the short leg brace was no longer necessary. No isolated inversion or eversion was observed. Muscle action in ankle dorsiflexion now permitted a functional gait. Wrist extension had undergone similar im provement, and hand-grasp, negligible be fore therapy, was approximately 30 to 50 per cent (45 kg by hand dynamometer) of a nor mal individual's. The resulting improvement in the patient's handwriting ability is shown in Figures 2 and 3. 824
1. Amato A, Hermsmeyer C, Kleinman K: Use of electro myographic feedback to increase inhibitory control of spastic muscles. Phys Ther 53:1063-1066, 1973 2. Andrews J: Neuromuscular re-education of the hemiplegic with the aid of the electromyograph. Arch Phys Med Rehabil 45:530-532, 1964 3. Barber T (ed): Biofeedback and Self-Control. Chicago, Aldine-Atherton, 1971 4. Basmajian J, Kukulka C: Biofeedback treatment of foot-drop after stroke compared with standard reha bilitation technique. Arch Phys Med Rehabil 56:231233,1975 5. Black J, Lagerson J, Zohman L: A feedback device for teaching diaphragmatic breathing. Am Rev Respir Dis 100:335-348, 1969 6. Booker H, Rubrow R, Coleman P: Simplified feedback in neuromuscular retraining: An automated approach using electromyographic signals. Arch Phys Med Re habil 50:621-625, 1969 7. Brudny J, Grynbaum BL, Koreim J: Spasmodic Torti collis: Treatment by feedback display of EMG. Arch Phys Med Rehabil 55:403-408, 1974
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
nlirlr?
plegia by use of electromyographic device. Arch Phys Med Rehabil 54:320-322, 1973 12. Karlins M, Andrews L: Biofeedback: Turning On the Power of Your Mind. Philadelphia, J. B. Lippincott Co, 1972 13. Weiss T, Engel B: Operant conditioning of heart rate in patients with premature ventricular contractions. Psychosom Med 33:301-321, 1971
Now! One Source for All Burn Articles ,
-WIS*-'"
Now available in a single volume—all arti cles on burns which have been published in PHYSICAL THERAPY. Eighteen articles. A Paper, 73 pp, ilius, $4.00
wealth of information from a forty-year span of material. A handy reference source for the physical therapy practitioner.
Prepayment is required on all orders—price is subject to change without notice. Allow three weeks for delivery. All orders are sent postage paid. Make checks payable to:
American Physical Therapy Association 1156 15th St., N.W., Washington, D.C. 20005
Volume 56 / Number 7, July 1976
825
Downloaded from https://academic.oup.com/ptj/article-abstract/56/7/821/4568008 by Washington University School of Medicine Library user on 17 February 2019
8. Brudny J: Sensory feedback therapy as a modality of treatment in CNS disorders of voluntary movement. Neurology 10:925-932, 1974 9. Budzynski T, Stoyva J, Adler C: Feedback-induced muscle relaxation: Application to tension headache. J. Behav Ther Exp Psychiatr 1:205-211, 1970. 10. Segal J: Biofeedback as a medical treatment. JAMA 232:179-180, 1975 11. Johnson H, Garton W: Muscle re-education in hemi
