EMG Biofeedback and EMG Biofeedback and Insensitivity Insensitivity

Ric, Julie, Francesca Ric, Julie, Francesca

EMG Biofeedback- EMG Biofeedback- review review

• Technique enabling the individual to readily Technique enabling the individual to readily determine the activity levels of a particular determine the activity levels of a particular physiological process, and with training learn physiological process, and with training learn to control this process with an internalized to control this process with an internalized mechanism. mechanism.

• Results must require an effort from the Results must require an effort from the patient.patient.

• Muscle electrical signals (EMG record) Muscle electrical signals (EMG record) translated to audio and visual stimuli through translated to audio and visual stimuli through the use of a brain computer interface (BCI) or the use of a brain computer interface (BCI) or thought translation device. thought translation device.

How EMG Biofeedback How EMG Biofeedback works!works!

EMG Biofeedback EMG Biofeedback

• Visual and auditory stimuli are controlled through Visual and auditory stimuli are controlled through gain settings and thresholds.gain settings and thresholds. High gain settings = Sensitive (see results, and High gain settings = Sensitive (see results, and lower frustration)lower frustration) Low gain settings = Less Sensitive Low gain settings = Less Sensitive

• Treatment of paralysis often involves both settingsTreatment of paralysis often involves both settings• Thresholds allow for therapists to control how Thresholds allow for therapists to control how

much EMG activity must be present for activation much EMG activity must be present for activation of biofeedback.of biofeedback.

-paralyzed muscle tissue often shows small -paralyzed muscle tissue often shows small EMG EMG activity; high gain settings coupled with the activity; high gain settings coupled with the use of use of thresholds prevent biofeedback signal thresholds prevent biofeedback signal from this from this activity activity

Biofeedback as Biofeedback as Treatment Treatment

• EMG has been used since early 60’s to help EMG has been used since early 60’s to help diagnose and treat neuromuscular disorders diagnose and treat neuromuscular disorders such as paralysis.such as paralysis.

• Therapists integrate EMG with other Therapists integrate EMG with other interventions for best resultsinterventions for best results

• Advantages:Advantages:- Increase self reliance of patient during - Increase self reliance of patient during

rehab rehab (empowerment)(empowerment)- Inexpensive – 1- Inexpensive – 1stst session = $300 session = $300

Additional Additional sessions = $150sessions = $150- Non-invasive - Non-invasive

Electrode Placement Electrode Placement

• Surface electrodes record broad activitySurface electrodes record broad activity• Distant muscle signal is lessened due to Distant muscle signal is lessened due to

impedance of muscle fibersimpedance of muscle fibers• Proximity is important but it is impossible to Proximity is important but it is impossible to

know exactly what muscle fibers are being know exactly what muscle fibers are being recorded (often placed 2’’ apart parallel to recorded (often placed 2’’ apart parallel to dominant muscle fiber)dominant muscle fiber)

• Improved technology allows for more Improved technology allows for more accurate readings as low as .08accurate readings as low as .08µV (myoscan µV (myoscan and myotrac)and myotrac)

EMG uses with EMG uses with insensitivity insensitivity

• CNS:CNS:- - hemiplegiahemiplegia- results from stroke causing paralysis - results from stroke causing paralysis in one side of the bodyin one side of the body- - paraplegia /quadriplegia-paraplegia /quadriplegia- results from nerve results from nerve damage or severe injury to CNS causing paralysis damage or severe injury to CNS causing paralysis

inin extremities extremities --Amyotrophic Lateral Sclerosis (ALS)Amyotrophic Lateral Sclerosis (ALS) – wasting – wasting away of muscle due to inactivity and scaring of away of muscle due to inactivity and scaring of motor neuronsmotor neurons--Cerebral Palsy-Cerebral Palsy- paralysis resulting from brain paralysis resulting from brain injury before, during, or shortly after birthinjury before, during, or shortly after birth

• Peripheral:Peripheral:--Bell’s Palsy-Bell’s Palsy- facial paralysis resulting from facial paralysis resulting from

damaged neurons damaged neurons --Injury- Injury- any damage of peripheral neurons any damage of peripheral neurons

resulting from injury resulting from injury

Paralysis Study (injury)Paralysis Study (injury)• Dr. Brucker (1996)- 100 long term spinal cord injury patients Dr. Brucker (1996)- 100 long term spinal cord injury patients

with no improving muscle activity in triceps (within subjects with no improving muscle activity in triceps (within subjects design) design)

• All patients received 45 mins of BFT for tricep extensions All patients received 45 mins of BFT for tricep extensions -75 of 100 receive additional treatments-75 of 100 receive additional treatments

• EMG data shows significant improvement after 1 session and EMG data shows significant improvement after 1 session and increased improvement with each subsequent treatmentincreased improvement with each subsequent treatment

• Biofeedback is effective for increasing voluntary EMG Biofeedback is effective for increasing voluntary EMG responses in this sample.responses in this sample.

ALS ALS • ““Lou Gehrig’s Disease” – progressive Lou Gehrig’s Disease” – progressive

neurodegenerative disease effecting motor neurodegenerative disease effecting motor neurons in CNSneurons in CNS

• Mind often remains unaffected but can no longer Mind often remains unaffected but can no longer control motor functions (lack of myelin sheath)control motor functions (lack of myelin sheath)• Symptoms:Symptoms:

- muscle weakness in - muscle weakness in speechspeech and breathing and breathing (60%)(60%)

- twitching/cramping in- twitching/cramping in hands/feet hands/feet - thinning/impairment of - thinning/impairment of arms/legs arms/legs - “thick” speech, low - “thick” speech, low

projection projection - complete paralysis - complete paralysis

ALS- a challenge to ALS- a challenge to biofeedback biofeedback

• EMG useful for diagnosis, problematic for EMG useful for diagnosis, problematic for rehabilitation rehabilitation

• Damage of nerve cells prevents EMG Damage of nerve cells prevents EMG improvement without some miracle improvement without some miracle drug… biofeedback cannot repair such a drug… biofeedback cannot repair such a problemproblem

• Fortunately, ALS doesn’t invade the mind. Fortunately, ALS doesn’t invade the mind. This means EEG biofeedback can be used This means EEG biofeedback can be used to translate thoughtsto translate thoughts

Cerebral Palsy and Cerebral Palsy and BiofeedbackBiofeedback

• Non-degenerative chronic disorder Non-degenerative chronic disorder impairing muscle controlimpairing muscle control

• Physical and occupational therapy allow Physical and occupational therapy allow for independence of patient for independence of patient

• EMG biofeedback used for speech EMG biofeedback used for speech improvement and better control of improvement and better control of voluntary movementsvoluntary movements

• Like ALS, biofeedback is not sufficient in Like ALS, biofeedback is not sufficient in recovery recovery

Conversion Paralysis and Conversion Paralysis and EMG EMG

• Uncommon neuro-dysfunctional condition Uncommon neuro-dysfunctional condition resulting from psychological conflict in stress and resulting from psychological conflict in stress and sporadic episodes sporadic episodes

• Patient convinces himself that an extremity has Patient convinces himself that an extremity has no sensation or movement.no sensation or movement.

• Treatment:Treatment:- Fishbain (1988) 4 patients with conversion - Fishbain (1988) 4 patients with conversion paralysis were successfully treated with BFTparalysis were successfully treated with BFT-EMG record showed significant -EMG record showed significant

improvementimprovement of functional capacity in afflicted of functional capacity in afflicted extremities extremities

ReferencesReferences

Asfour, S., Fishbain, D., Goldberg, M., & Khalil, T. (1988). Utility of Asfour, S., Fishbain, D., Goldberg, M., & Khalil, T. (1988). Utility of

electromyographic electromyographic

biofeedback for the treatment of conversion paralysis. biofeedback for the treatment of conversion paralysis. American-American-

Journal-of-Journal-of- PsychiatryPsychiatry. Vol 145(12), 1572-1575. Vol 145(12), 1572-1575

Berkow, Robert (1997). Berkow, Robert (1997). Merck Manual of Medical InformationMerck Manual of Medical Information. New York: . New York:

Pocket Books.Pocket Books.

Brucker BS and Bulaeva NV (1996). Biofeedback effect on electromyography Brucker BS and Bulaeva NV (1996). Biofeedback effect on electromyography

responses in responses in

patients with spinal cord injury. patients with spinal cord injury. Arch Phys Med Rehabil. 77 (2):Arch Phys Med Rehabil. 77 (2): 133-7. 133-7.

The ALS Association. (2006) <http://www.alsa.org/>The ALS Association. (2006) <http://www.alsa.org/>

Elder, S.T. (1982) Amyotrophic lateral sclerosis: A challenge for biofeedback. Elder, S.T. (1982) Amyotrophic lateral sclerosis: A challenge for biofeedback.

American-American-

Journal-of-Clinical-Biofeedback 5(2), 123-125.Journal-of-Clinical-Biofeedback 5(2), 123-125.

http://www.electrotherapy.org/electro/biofeedback/biofeed1.htmhttp://www.electrotherapy.org/electro/biofeedback/biofeed1.htm

http://www.bio-medical.com/news_display.cfm?mode=EMG&newsid=26http://www.bio-medical.com/news_display.cfm?mode=EMG&newsid=26

Facial and Vocal Facial and Vocal Paralysis Paralysis

Rehabilitation Rehabilitation using EMGusing EMG

OutlineOutline

• General information about EMG General information about EMG

• Facial Paralysis RehabilitationFacial Paralysis Rehabilitation• Vocal Paralysis RehabilitationVocal Paralysis Rehabilitation

• Interesting Applications of EMG Interesting Applications of EMG biofeedback in relation to paralysisbiofeedback in relation to paralysis

EMG in MedicineEMG in Medicine

• Two MethodsTwo Methods– Subdermal Needle EMG & Surface Subdermal Needle EMG & Surface

EMGEMG

• Used in Voluntary Muscle ControlUsed in Voluntary Muscle Control– Reduction of activity and restoration of Reduction of activity and restoration of

activityactivity

• Used to alleviate muscle tensionUsed to alleviate muscle tension• Applications for migrane headachesApplications for migrane headaches

Facial RehabilitationFacial Rehabilitation

• Treatment Techniques: Treatment Techniques:

exercise, electrical stimulation, exercise, electrical stimulation, biofeedback, and neuromuscular biofeedback, and neuromuscular retraining for facial paresisretraining for facial paresis

• Sunderland third-degree injuries Sunderland third-degree injuries benefit most from EMG therapy benefit most from EMG therapy

• Muscle re-education using surface Muscle re-education using surface EMG biofeedback and home EMG biofeedback and home exercises is efficient in treatment of exercises is efficient in treatment of facial palsies facial palsies

Facial RehabilitationFacial Rehabilitation

• EMG treatments also useful for:EMG treatments also useful for:

poliomyelitis poliomyelitis

cerebrovascular accidents cerebrovascular accidents

torticollis torticollis

nerve injury nerve injury

temporomandibular joint syndrometemporomandibular joint syndrome

bruxism and other disordersbruxism and other disorders

Facial RehabilitationFacial Rehabilitation• The effectiveness of The effectiveness of

neuromuscular facial retraining neuromuscular facial retraining combined with electromyography combined with electromyography in facial paralysis rehabilitationin facial paralysis rehabilitation – Tested 24 patients over a 2 year periodTested 24 patients over a 2 year period– After retraining using EMG stimulation, After retraining using EMG stimulation,

facial muscle control improved by 2 facial muscle control improved by 2 levels.levels.

– Concluded:Concluded:facial retraining exercises and facial retraining exercises and EMGEMG are are effective for improving facial movements effective for improving facial movements post paralysis post paralysis

Facial RehabilitationFacial Rehabilitation• EMG rehabilitation of facial function EMG rehabilitation of facial function

and introduction of a facial paralysis and introduction of a facial paralysis grading scale for hypoglossal-facial grading scale for hypoglossal-facial nerve anastomosis.nerve anastomosis.

– 30 patients with no facial muscle control30 patients with no facial muscle control– Developed 6 point grading scale established to Developed 6 point grading scale established to

assess improvementassess improvement– Ten patients (33%) achieved the highest Ten patients (33%) achieved the highest

possible grading (II) with symmetry and possible grading (II) with symmetry and synchrony of function and spontaneity of synchrony of function and spontaneity of expression; 17 (57%) reached grade III, which expression; 17 (57%) reached grade III, which allowed voluntary control of eye and mouth allowed voluntary control of eye and mouth function; 3 (10%) showed minimal gains function; 3 (10%) showed minimal gains lasting between 3 and 18 monthslasting between 3 and 18 months

Facial RehabilitationFacial Rehabilitation• Facial Reanimation With Jump Interpositional Facial Reanimation With Jump Interpositional

Graft Hypoglossal Facial Anastomosis and Graft Hypoglossal Facial Anastomosis and Hypoglossal Facial AnastomosisHypoglossal Facial Anastomosis – Classically managed with HFA but this has Classically managed with HFA but this has

negative side effectsnegative side effects– The JIGHFA with gold weight lid implantation The JIGHFA with gold weight lid implantation

and (EMG) rehabilitation offered as alternativeand (EMG) rehabilitation offered as alternative– 18 JIGHFA patients compared with 30 HFA with 18 JIGHFA patients compared with 30 HFA with

EMG patientsEMG patients– JIGHFA resulted in substantial facial JIGHFA resulted in substantial facial

reinnervation in 83.3% of the patients without reinnervation in 83.3% of the patients without hemilingual sequelae which was seen in 45% of hemilingual sequelae which was seen in 45% of the HFA patients the HFA patients

Vocal Paralysis: What is Vocal Paralysis: What is it?it?

• Vocal fold paralysis and paresis result Vocal fold paralysis and paresis result from abnormal nerve input to the voice from abnormal nerve input to the voice box muscles (laryngeal muscles).  box muscles (laryngeal muscles).  

• Paralysis is the total interruption of nerve Paralysis is the total interruption of nerve impulse resulting in no movement of the impulse resulting in no movement of the musclemuscle

• Paresis (also possible) is the partial Paresis (also possible) is the partial interruption of nerve impulse resulting in interruption of nerve impulse resulting in weak or abnormal motion of laryngeal weak or abnormal motion of laryngeal muscle(s). muscle(s).

Vocal ParalysisVocal Paralysis• What nerves are involved?What nerves are involved?

• Superior Laryngeal Nerve (SLN):Superior Laryngeal Nerve (SLN): carries signals to the cricothyroid muscle carries signals to the cricothyroid muscle which adjusts vocal cord tension for which adjusts vocal cord tension for high/low pitcheshigh/low pitches

• Recurrent Laryngeal Nerve (RLN):Recurrent Laryngeal Nerve (RLN): signals to different voice box muscles signals to different voice box muscles responsible for opening vocal folds (as in responsible for opening vocal folds (as in breathing, coughing), closing vocal folds breathing, coughing), closing vocal folds for vocal fold vibration during voice use, for vocal fold vibration during voice use, and closing vocal folds during swallowing. and closing vocal folds during swallowing.

Vocal ParalysisVocal Paralysis

• Not simply inability to speakNot simply inability to speak

Can also affect: ability to swallowCan also affect: ability to swallow

cause shortness of breathcause shortness of breath

noisy breathingnoisy breathing

hoarseness hoarseness

unclear “breathy” voiceunclear “breathy” voice

breath use in sound breath use in sound productionproduction

Vocal ParalysisVocal ParalysisHow is it diagnosed?How is it diagnosed?

Laryngeal electromyography (LEMG):Laryngeal electromyography (LEMG): measures measures electrical currents in voice box muscles resulting electrical currents in voice box muscles resulting from nerve input information. Measuring and from nerve input information. Measuring and looking at patterns in electrical currents show looking at patterns in electrical currents show whether there is repair of nerve inputs (re-whether there is repair of nerve inputs (re-innervation) and the  extent of the nerve lesion or innervation) and the  extent of the nerve lesion or problem.   It works through the insertion of small problem.   It works through the insertion of small needles that can measure electrical currents in needles that can measure electrical currents in the vocal cord muscles. In LEMG testing, patients the vocal cord muscles. In LEMG testing, patients perform a number of tasks that would normally perform a number of tasks that would normally produce typical activity in the vocal muscles. produce typical activity in the vocal muscles.

Vocal ParalysisVocal Paralysis

So, the EMG technique is useful in So, the EMG technique is useful in evaluating patients with vocal cord evaluating patients with vocal cord paralysisparalysis

• Can pinpoint specific lesioning in Can pinpoint specific lesioning in unexplained vocal paralysisunexplained vocal paralysis

• Also can be used with other vocal Also can be used with other vocal disorders such as spasmodic dysphonia, disorders such as spasmodic dysphonia, vocal tremors, and the symptoms of vocal tremors, and the symptoms of progressive neurological diseases such as progressive neurological diseases such as myasthenia gravis.  myasthenia gravis. 

Vocal ParalysisVocal Paralysis

• Electromyography and the immobile Electromyography and the immobile vocal foldvocal fold– Laryngeal EMG functions as a prognostic tool Laryngeal EMG functions as a prognostic tool

in the evaluation of vocal fold paralysis, as a in the evaluation of vocal fold paralysis, as a guide for therapeutic injections into the guide for therapeutic injections into the laryngeal muscles, and as an assessment tool in laryngeal muscles, and as an assessment tool in the evaluation of the causes of vocal fold the evaluation of the causes of vocal fold paresis paresis

– Laryngeal Laryngeal EMGEMG in the paralyzed vocal fold can in the paralyzed vocal fold can guide diagnosis and treatment by pointing to guide diagnosis and treatment by pointing to the site of the lesion the site of the lesion

– Guides management of and evaluation of Guides management of and evaluation of motion disorders of larynx.motion disorders of larynx.

Interesting ApplicationsInteresting Applications

• The utilization of EMG biofeedback The utilization of EMG biofeedback for the treatment of periorbital facial for the treatment of periorbital facial muscle tension muscle tension – Reduced firing in upper and lower eye, Reduced firing in upper and lower eye,

reported reduced tension after 20 reported reduced tension after 20 sessionssessions

– 3 months later, subjects reported 3 months later, subjects reported complete elimination of all muscle complete elimination of all muscle tension in orbital areatension in orbital area

Interesting ApplicationsInteresting Applications

• Crocodile Tear SyndromeCrocodile Tear Syndrome– botulinum toxin treatment under botulinum toxin treatment under

EMG guidanceEMG guidance – Rare complication of facial paralysisRare complication of facial paralysis– carry out the injection of botulinum toxin carry out the injection of botulinum toxin

under EMG guidance in order to inject under EMG guidance in order to inject botulinum toxin selectively into the botulinum toxin selectively into the lacrimal gland to protect palpebral, lacrimal gland to protect palpebral, lateral rectus, and superior rectus lateral rectus, and superior rectus muscles.muscles.

SourcesSources

Cronin GW. (2003). Cronin GW. (2003). The effectiveness of neuromuscular The effectiveness of neuromuscular facial retraining combined with electromyography in facial facial retraining combined with electromyography in facial paralysis rehabilitation. Otolaryngol Head Neck Surg - 01-paralysis rehabilitation. Otolaryngol Head Neck Surg - 01-APR-2003; 128(4): 534-8APR-2003; 128(4): 534-8

Brundy, J., Hammerschlag PE, Cohen NL, Ransohoff J. (2002). Brundy, J., Hammerschlag PE, Cohen NL, Ransohoff J. (2002). Electromyographic rehabilitation of facial function and Electromyographic rehabilitation of facial function and introduction of a facial paralysis grading scale for introduction of a facial paralysis grading scale for hypoglossal-facial nerve anastomosis. hypoglossal-facial nerve anastomosis. Department of Department of Rehabilitation Medicine, New York University School of Rehabilitation Medicine, New York University School of Medicine. (all)Medicine. (all)

Hammerschlag, Paul E. MD (1999) Facial Reanimation With Hammerschlag, Paul E. MD (1999) Facial Reanimation With Jump Interpositional Graft Hypoglossal Facial Anastomosis Jump Interpositional Graft Hypoglossal Facial Anastomosis and Hypoglossal Facial Anastomosis: Evolution in and Hypoglossal Facial Anastomosis: Evolution in Management of Facial Paralysis. Management of Facial Paralysis. Laryngoscope. Laryngoscope. 109 (2, 109 (2, Part 2) SUPPLEMENT NO. 90: 1-23.Part 2) SUPPLEMENT NO. 90: 1-23.

Daniel B, Guitar B. (1978). EMG Feedback and Recovery of Daniel B, Guitar B. (1978). EMG Feedback and Recovery of facial and speech gestures following neural anastomosis. facial and speech gestures following neural anastomosis. J J Speech and Hearing Disorders. Speech and Hearing Disorders. Feb: 43(1): 9-20.Feb: 43(1): 9-20.

SourcesSources

Novak C. (2004). Rehabilitation Strategies for Facial Novak C. (2004). Rehabilitation Strategies for Facial Nerve Injuries. Nerve Injuries. Seminars in Plastic Surgery. Seminars in Plastic Surgery. 18: 47-18: 47-51.51.

Sulica L. (2004). Electromyography and the immobile Sulica L. (2004). Electromyography and the immobile vocal field. vocal field. Otolaryngol Clin. North Am. Otolaryngol Clin. North Am. 37(1): 59-37(1): 59-74.74.

Miller S. (2004). Voice Therapy for Vocal Fold Miller S. (2004). Voice Therapy for Vocal Fold Paralysis. Paralysis. Otolaryngol Clin. North Am. Otolaryngol Clin. North Am. 37(1):105-1937(1):105-19

Paniello RC. (2004). Laryngeal Reinnervation. Paniello RC. (2004). Laryngeal Reinnervation. Otolaryngol Clin. North Am. Otolaryngol Clin. North Am. 37(1): 161-81.37(1): 161-81.

Kizkin S. (2005). Crocodile Tears Syndrome: Kizkin S. (2005). Crocodile Tears Syndrome: Botulinum Toxin Treatment under EMG Guidance. Botulinum Toxin Treatment under EMG Guidance. Funct. Neurology. Funct. Neurology. 20(1): 35-7.20(1): 35-7.

StrokeStroke

• Ischemic ~ 80% of all strokesIschemic ~ 80% of all strokes– Blood vessel blockedBlood vessel blocked

• ThromboticThrombotic• EmbolicEmbolic• Systematic HypoperfusionSystematic Hypoperfusion• Venous ThrombosisVenous Thrombosis

• HemorrhagicHemorrhagic– Blood vessel rupturesBlood vessel ruptures

• IntracerebralIntracerebral• SubarachnoidSubarachnoid

ParalysisParalysis

• HemiplegiaHemiplegia– Paralysis on one side of bodyParalysis on one side of body– Lesion in corticospinal tractLesion in corticospinal tract– Contralateral motor controlContralateral motor control

• HemiparesisHemiparesis– Weakness or partial paralysisWeakness or partial paralysis– Less severe than HemiplegiaLess severe than Hemiplegia

ElectromyographyElectromyography

• Only 5% regain full motor controlOnly 5% regain full motor control• 20% don’t regain any function20% don’t regain any function• Significantly lower EMG in agonistic Significantly lower EMG in agonistic

muscles groupsmuscles groups– No difference in antagonistic musclesNo difference in antagonistic muscles– Treatment should target motor neuron Treatment should target motor neuron

recruitmentrecruitment

EMG BiofeedbackEMG Biofeedback

• Visual or auditory Visual or auditory signalssignals

• Computer gamesComputer games• Strengthen agonist Strengthen agonist

muscle groupsmuscle groups• Relax/inhibit Relax/inhibit

antagonist muscle antagonist muscle groupsgroups

• Gait trainingGait training

Stroke TreatmentStroke Treatment

• ‘‘Motor copy’ biofeedback trainingMotor copy’ biofeedback training– EMG biofeedback from EMG biofeedback from unaffectedunaffected

musclesmuscles– Train patients to produce matching Train patients to produce matching

activity in paretic musclesactivity in paretic muscles– Longer-lasting results than typical Longer-lasting results than typical

biofeedback groupbiofeedback group

Stroke TreatmentStroke Treatment

• Constraint-induced Constraint-induced movement therapymovement therapy– Restrain functional Restrain functional

limb so that patient limb so that patient is forced to retrain is forced to retrain weak musclesweak muscles

– Progress monitored Progress monitored by TMS mapping of by TMS mapping of primary motor primary motor cortexcortex

– Combined with EMG Combined with EMG StimulationStimulation

Functional Tone Functional Tone ManagementManagement

• Helps patients Helps patients regain hand regain hand functionfunction

• Current studies Current studies monitoring cortical monitoring cortical reorganizationreorganization

• Incorporate EMG Incorporate EMG recording to recording to measure measure improvement?improvement?

ReferencesReferencesFritz, S. L., Chiu, Y., Malcolm, M.P., Patterson, T.S. and Light, K.E.. (2005) Fritz, S. L., Chiu, Y., Malcolm, M.P., Patterson, T.S. and Light, K.E.. (2005)

Feasibility of electromyography-triggered neuromuscular stimulation as Feasibility of electromyography-triggered neuromuscular stimulation as an adjunct to constraint-induced movement therapy. an adjunct to constraint-induced movement therapy. Physical TherapyPhysical Therapy    85.5: 428-443.85.5: 428-443.

Barker, E. (2005). New hope for stroke patients: a new therapy offers hope Barker, E. (2005). New hope for stroke patients: a new therapy offers hope that movement will be restored to weakened limbs following a stroke. that movement will be restored to weakened limbs following a stroke. RNRN    68.2: 38-44.68.2: 38-44.

Gowland, C., deBruin, H., Basmajian, J. V., Plews, N., and Burcea, I.  Agonist Gowland, C., deBruin, H., Basmajian, J. V., Plews, N., and Burcea, I.  Agonist and antagonist activity during voluntary upper-limb movement in patients and antagonist activity during voluntary upper-limb movement in patients with stroke.  with stroke.  Physical TherapyPhysical Therapy  72.n9 624-634.  72.n9 624-634.

"A Rehab Revolution," Stroke Connection Magazine, September/October "A Rehab Revolution," Stroke Connection Magazine, September/October 20042004http://www.strokeassociation.org/presenter.jhtml?identifier=3029938http://www.strokeassociation.org/presenter.jhtml?identifier=3029938

http://en.wikipedia.org/wiki/Stroke#Signs_and_symptomshttp://en.wikipedia.org/wiki/Stroke#Signs_and_symptoms