The added value of a series of Brucker Biofeedback therapy treatments Case Study Patient M

Transcription

1 The added value of a series of Brucker Biofeedback therapy treatments Case Study Patient M Authors: Thomas Verhoogt, MSc Human Movement Scientist Matthias Krieger, Physical Therapist, Head Therapist Brucker Biofeedback Center Rotterdam, the Netherlands Rotterdam, 14 th of June,

2 Introduction The case study will be a descriptive report about the results of the Brucker Biofeedback Method for Patient M. The Brucker Biofeedback Method is a special operant conditioning method, with which people are able to efficiently use existing motor neurons in the central nervous systems. This method is invented and developed by Professor Bernard Brucker, an American psychologist and neuroscientist. His idea was based on the theory of the neuroplasticity of the brain. So called neuroplastic change can occur on different levels, from small scales as in changes to individual neurons, as well as on bigger brain areas. Brucker stated that new neuronal connections between central nervous systems and the muscles are formed, which could be used instead of the regular pathways in the central nervous systems which are damaged (Weber, 2011). In short, using another pathway of nerves to do the same movement. The theory is based on the trial-and-error principal. Reiner (2015) explains this by the example of someone who wants to learn playing the piano. At the beginning, the challenge of playing the piano will be difficult, you have to find out how you will be able to functional use the instrument. However, when this is clear, you could fine-tune the sounds with the use of acoustic feedback. After a while, playing the piano will become easy, it will be of an automatic behaviour. Based on specific visual EMG-feedback this is also possible for the learning of a new muscle movement. The Brucker Biofeedback Method helps finding the correct pathway for the signals to control the muscles. For the therapy it is extremely important to reward someone with positive feedback when the correct connection for a specific muscle movement is found. Extrinsic as well as intrinsic motivation are highly important for locomotive learning (van den Berg, 2001). By doing a correct movement, learn to control a specific muscle movement, patients are able to visually see this on a screen and/or hear this by a tone (visual or auditive feedback). The aim is to constantly recall this correct muscle movement with the according stimuli. By setting so called trainer lines the therapist can challenge the patient to expand his or her muscle management skills. Saving this new neuron connections in his or her long term memory, will occur through repeatedly recalling and practising these specific movements. The trainer lines can be understood as the target which the patient has to reach. These lines increase (or decrease, due to task) during the therapy sessions and if a certain level is reached the desired creation of new pathways is taking place. Patient M ( ; 14 YOA) is diagnosed with a cerebral palsy, which is represented in a spastic dystonic image (GMFCS-4, MACS-3) and a cerebral visual impairment, both due to anoxia during birth. The motorical difficulties don t allow M to stand on his own. He is able to sit for a limited amount of time without support. For his daily activities he uses an electric wheelchair, which he is able to handle alone. M has developed a typical, individual movement pattern in order to compensate his insufficient trunk control, by bringing his arms into a flexed position, his pelvis in an extension and his legs in an adduction and internal rotation. Additional, a (hyper) extension in his hips as well as an extension of his neck, bending his head backwards. He uses his pattern mostly before specific and voluntary movements, with certain emotions and/or when he is triggered by unexpected distractions. At the start of the therapy three main goals were defined. The first goal was to improve trunk control and therewith stability. The second goal was to increase support during transfers from a sitting to a standing position and daily live activities, as well as increasing the activity while standing. 2

3 And the third goal was to improve functionality of his right arm. There are several sub goals which will come to attention during the therapy session, including reducing automatic movement pattern of the arms, attention on the centralisation of the head and improving his concentration. The patient will follow eleven BBFM sessions during a time period of five weeks, in addition to his regular physical therapy program. Method Materials and programs At the Brucker Biofeedback Center we work with the ProComp Infiniti. It s an 8 channel, biofeedback and neurofeedback system with the power needed for real-time data acquisition in any clinical or educational setting. With surface electrodes which are connected via special cables to the ProComp Infiniti are used to measure the smallest signals passed from the CNS to the muscles. This ProComp Infiniti is connected through a Bluetooth connection with a computer. The specially designed software, named Biograph Infiniti, makes it possible to register and reproduce the exact visual and/ or auditive feedback without any time delay. On the screen in front of the patient the tiniest activation of the muscles is shown in real time. This immediate feedback is very important for the patient to understand and save that feedback with the correct movement. In the therapy setting with patient M, we chose to use not only the visual feedback on the screen but an auditive feedback as well (patient will hear a specific sound when the desired target is reached), due to cerebral visual impairment of patient M. Moreover, verbal encouragement is added to maximize the motivation of the patients. As already mentioned in the introduction, intrinsic and extrinsic motivations are key factors for the success of the Brucker Biofeedback treatment. Muscle groups and movements In the first session all necessary EMG data (in mv) of each muscle group, according to the upfront defined goals, had been collected and this data had been used as a start point. The first and last session of each muscle group had been compared and the average development (in mv) reflected the progress M made. The muscle groups for the improvement of the trunk and head stability were the para-spinal back muscles between the fourth and twelfth thoracic vertebra, and the bilateral abdominals. Concerning the second goal, to increase support during transfers from a sitting to a standing and daily live activities, as well as increasing the activity while standing the bilateral knee extensors were trained. The segment statistics are analysed for an interval of twenty seconds, in which the patient needed to participate as much as possible. For the last defined goal, which was to improve the usage of his right arm, we laid the focus on a more physiological and functional movement of bending and extending his arm and worked with the biceps and triceps of the right arm. The intention here was to learn patient M to send the correct signals to his upper arm muscles when doing an elbow flexion/ extension. So, the importance isn t on the exact values but on the correct control of agonist and antagonist. By lack of an official test we chose to make movies (in possession of the Brucker Biofeedback Center Rotterdam) at the start and at the end of the study while the patient performed two exercises. 3

4 This way it was possible to give an indication for the progress made during the therapy. The two exercises were; sitting without stabilisation for a long as possible and standing up from a sitting position while getting minimal support from the therapist. Comparisons are made on the basis of the time period patient M is sitting or standing. The quality and support of M while transfers and daily live activities can only be interpreted in a subjective way and therefore this part is not added to this case study. Results Increase trunk stability The results for the first goal of improving the trunk stability of patient M are best displayed by comparison of the average activity of the first sessions and the last sessions, while performing the exercises for the abdominals and back extensors. Table 1: segment statistics abdominals first session (EMG C = right side, EMG D = left side). Average St. Dev Variabilit y Area Table 2: segment statistics abdominals final session Average St. Dev. Variabilit y Area The abdominals show a clear difference between the averages (in mv) at the start and at the first session compared to the last session. Note that the maximum peak power during a 20 seconds interval is also higher at the end of the BBFM therapy. Besides, the improvement of the control of the abdominal muscles, the back muscles also contribute to improvement of trunk (and head) stability. Therefore, the results of the para-spinal back muscles between several vertebras are shown in the tables below. 4

5 Table 3: segment statistics back extensors t4-t6 first session (EMG C = right side, EMG D = left side). Average St. Dev Variabilit y Area Table 4: segment statistics back extensors t4-t6 last session Average St. Dev Variabilit y Area The results state that the back extensors between t4 and t6 show an increased activity (in mv) at the end of the Brucker Biofeedback therapy, compared to the beginning of the therapy. Table 5: segment statistics back extensors t6-t8 first session (EMG C = right side, EMG D = left side). Average St. Dev Variabilit y Area Table 6: segment statistics back extensors t6-t8 last session Average St. Dev Variabilit y Area The results state that the back extensors between t6 and t8 show an increased activity (in mv) at the end of the Brucker Biofeedback therapy, compared to the beginning of the therapy, with a significant difference between left (EMG C) and right (EMG D). 5

6 Table 7: segment statistics back extensors t8-t10 first session (EMG C = right side, EMG D = left side). Average St. Dev. Variability Area Table 8: segments statistics back extensors t8-t10 last session Average St. Dev. Variability Area The results state that the back extensors between t8 and t10 show an increased activity (in mv) at the end of the Brucker Biofeedback therapy, compared to the beginning of the therapy. Table 9: segment statistics back extensors t10-t12 first session (EMG C = right side, EMG D = left side). Average St. Dev. Variability Area Table 10: segment statistics back extensors t10-t12 last session Average St. Dev. Variability Area The average activity (in mv) over a time period of twenty seconds shows a clear distinction for t10- t12, between the sample took out of the first session compared to the last session. The area between the tenth and the twelfth thoracic vertebra is the lowest segment which was measured every session. Note that this doesn t mean that the rest of his back muscles didn t improve as well. It just means that those segment weren t measured because we defined our goal setting on the most important areas for patient M. 6

7 Increase transfer sit to stand The second goal was to increase the support Patient M could offer during transfers from a sitting to a standing position and vice versa. In table 9 and table 10 the activity (in mv) is shown for the quadriceps during a transfer at the beginning and at the end of the therapy. Table 11: Segments statistics quadriceps sit-to-stand initial values (EMG C = right leg, EMG D = left leg). Average St. Dev. Variability Area Table 12: Segments statistics quadriceps sit-to-stand final values (EMG C = right leg, EMG D = left leg). Average St. Dev. Variability Area The results state that the quadriceps shows an increased activity (in mv) at the end of the Brucker Biofeedback therapy, compared to the beginning of the therapy. It is fair to state that patient M made reasonable progress with the specific control of the quadriceps. This alone does not guarantee that he could stand on his own but does influence the help he could offer during a transfer. Improve functionality right arm The results of the training of the right arm are shown in the graphs below. They show how the patient is able to control his muscle activity in his upper arm. His task was to show a voluntarily elbow extension in which the triceps had been the agonist and the biceps the antagonist. Figures 1 till 4 represent the control of the biceps and triceps during an extension of the elbow. The graphs of figures 5 till 9 represent the same muscles but now while trying to perform an elbow flexion. During the extension movement in the first session the patient has too much tension in his biceps (blue line). When you look at figures 3 and 4 for the last session you could see that the patients was able to reduce the tension of the biceps (blue line). The patient now has the skills to activate his triceps (yellow line) which is necessary for a physiological elbow extension of the right arm. So, at first, the patient has trouble sending the correct information to the muscles. At the end of the of the Brucker Biofeedback therapy the patients understands which signals are the correct ones for an extension of his arm. 7

8 Figure 1: segments statistics elbow extension first session (biceps = blue line / triceps = yellow line). 8

9 Figure 2: segments statistics elbow extension first session (biceps = blue line / triceps = yellow line). Figures 1 and 2 clearly show that the patient is using his biceps, while instead he needs to use his triceps for a correct execution of an elbow extension. By the large difference between the two graphs you could assume that he just doesn t know how to do this, because the more he tries the more tension he creates in his biceps. 9

10 Figure 3: segments statistics elbow extension last session (biceps = blue line / triceps = yellow line). 10

11 Figure 4: segments statistics elbow extension last session (biceps = blue line / triceps = yellow line). Figures 3 and 4 show the correct control of the upper arm muscles for an elbow extension. In figure 4 he is even able to reach the training line set by the therapist. The patient not only shows that he could give the correct signals to his arm for a proper control of his muscles, but also shows that he could produce a sufficient activity, while doing so. When looking at the graphs for the elbow flexion (figures 5 till 9) in which now the biceps is seen as the agonist and the triceps the antagonist. You could see that during the first session the patient doesn t have the ability to correctly control his upper arm muscles. He is using a lot of uncontrolled movements trying to accomplish an elbow flexion. Again, it isn t clear for him which muscle should be working and which muscle should be relaxing. In the last session of the Brucker Biofeedback therapy the patient sends the correct signals to his right arm. You can that he improved a lot and is now able to voluntarily inhibit the activity off his triceps (yellow line), while gradually controlling his biceps (blue line). 11

12 Figure 5: segment statistics elbow flexion first session (triceps = yellow line / biceps = blue line). Figure 6: segment statistics elbow flexion first session (triceps = yellow line / biceps = blue line). Figure 5 and 6 show an uncoordinated and unnecessary movement of his biceps (blue) while flexing his arm. These graphs are most likely due to his specific individual movement pattern, which we discussed in the introduction. His tendency to using the pattern is deeply embedded in his automatic movement behaviour. So, at the beginning of the therapy patient M was already able to flex his 12

13 arms. However, the challenge for him was to better understand the movement and perform this in a more controlled and physiological manner. Figure 7: segment statistics elbow flexion last session (triceps = yellow line / biceps = blue line). Figure 8: segment statistics elbow flexion last session (triceps = yellow line / biceps = blue line). 13

14 Figure 9: segment statistics elbow flexion last session (triceps = yellow line / biceps = blue line). In the last three figures, you can see that the patient found a much better and more physiologic way on how to use his upper arm muscles. As clearly visible in Figure (between 01:45 and 01:46) he learned how to control these movements, because his task was to only use his biceps (blue line) and should keep the line of his triceps (yellow) below the purple one. On the basis of a trainings line in figure 8 and 9, the patient is able to reach the goals and controls his muscles on a sufficient manner to produce a correct movement. Overall, patient M has trouble sending the correct information to the muscles of his upper arm. This is probably due to his specific movement pattern that he is and has been using for many years. Part of the Brucker Biofeedback therapy was to create a better understanding between difference of an extension and a flexion of his right arm. Correctly controlling the muscles by sending the correct signals from the central nervous system to the motor neurons in his right arm. The results showed that this did happen. The aim is, by training and using his arm in the new correct way, which he has learned in the five weeks of Brucker Biofeedback therapy, to save this new correct information in his long term memory. So, it will eventually become more and more and automatic behaviour. Results from video sequences On the first day of our therapy block we made two videos (in possession of the Brucker Biofeedback Center Rotterdam) with M. One showed his ability so sit without any support (feet were on the ground), while his therapist sat next to him for safety reasons, without helping him. The second video showed the 14

15 transfer from a sitting to a standing position and here we took the time how long M could stand with minimal support of his therapist. Due to not existing tests we chose to take the time how long M could sit and stand and compared these. free sit (in min:sec) standing (in min:sec) before BBFM 02:47 00:19 after BBFM 03:59 01:12 Improvement 01:12 00:53 Discussion In this report the results of the Brucker Biofeedback Method were summarized for patient M. This is a descriptive report in which the results are illustrated by a licensed Brucker Biofeedback therapist to inform about this relatively new therapy method. Note that this is an individual case of patient M and can t be randomised to a whole population. However, this descriptive case report does point out the advantages of the Brucker Biofeedback Method for individuals with damage to the central nervous system. Patient M worked, during eleven sessions within five weeks, on three main goals. Improving trunk stability, increase support during transfers from a sitting to a standing position and increase support with daily live activities, as well as increasing the activity while standing. The results showed an improvement on all three goals. Patient M has created a better awareness of the central position of his body. He has shown that he is able to build up more tension around the thoracic levels of his spine. Furthermore, it was, strikingly positive, that patient M could compensate his posture whenever his body of mass had the tendency to fall over. Combined with the data, this assumes an improvement of his overall stability. Concerning the second goal, it was important for patient M to learn how he could help during a transfer from a sitting to a standing position, furthermore be more active and supportive in daily live activities. This is of importance because M will soon be heavier and it will be harder for others to constantly lift him, besides various other positive aspects of the standing position of course. From this point the patient must keep training them, so they become stronger and will be of sufficient use during transfers. The improvement of the functional use of the right arm was hard to measure because M quickly falls back in his pattern. Therefore, the focus shifted towards the correct control of the elbow. It was important to learn M the difference between extension and flexion of his elbow. These are of essence for him to give a better functional use for his right arm, for example by using his arms as a stabilisation point. As the graphs have shown, patient M did show a clear difference before and after the therapy. At first he was searching for the correct control and had trouble relaxing the antagonist when the agonist had to do the work, and the other way around. At the end, there was a huge difference, the patient could relax his muscles and clearly understood that the biceps has to work during flexion and the triceps during extension. This way it will be easier for him to use his arm in daily life. Overall, patient M adapted well to the Brucker Biofeedback therapy. It was obvious that he did follow the advice of the therapist during the sessions as well as doing his homework, training his new learned movements, which led to an increased intrinsic motivation as well. 15

16 In addition, the two exercises M performed at the start and again at the end of the therapy, also indicate that the trunk stability as well as the ability to better use his quadriceps, improved. Patient M could sit without any support for 0at the start of the therapy and for 02:47 minutes and at the end of therapy for 03:59 (improvement of 01:12 minutes). M was also able of standing while holding the therapist at his shoulders, for a longer period of time after the Brucker Biofeedback therapy than that he was able to do before the therapy sessions (improvement by 00:53 seconds). Note that the exercise at the end of therapy were done before the sessions started, taking into consideration the possible fatigue afterwards. Again, these exercises aren t scientifically based on an official test but the results are in line with expected outcome after participating the therapy. Important to know is that the Brucker Biofeedback therapy is not an alternative for another therapy but must be seen as an additional therapy alongside other therapies. With the ability to measure and directly, without any time delay, show the smallest signals / muscle contractions, the patient and the therapist has an objective vision of the function of important nerve- muscle connections. This knowledge must be incorporated in other possible therapies patients are following. As in the case of patient M, he did use his new learned movements not only during his homework from the Brucker Biofeedback therapist but also during his regular physiotherapy. To get back at the piano-example of Reinier (2015); only by repeatedly using the learned skills, the execution of the movement will become easier and better until it becomes an automatic behaviour. Future ideas concerning to improve the mobility of patient M especially related to the goals of improving trunk/head stability, improving support during transfers and/or improving the functionality of the arms, were discussed with our patient, his mother and his caretaker. We based our homework/ exercise program on the exercises M performed while his therapy sessions. Conclusion The Brucker Biofeedback therapy did appear to be beneficial for Patient M. It would be interesting to see how his progress will develop over time. However, it can t be said enough, that the Brucker Biofeedback Method only offers the possibilities and opportunities of the human body. Whatever the patient does with these chances, determines if the movements could eventually be functional used in his or her daily life. In others words; if you don t use it, you will lose it. Concluding, this case report underpins the suggestion that the method could be helpful for patients with brain damage to learn specific muscle movements. De Biase et al. (2011) suggested that EMGbiofeedback contributes to a cortical reorganisation. Based on the same principal, the Brucker Biofeedback seems to support the ability to learn new neuromuscular excitation. However, further study is necessary to scientifically confirm these suggestions. 16

17 Literature De Biase, M. E. M., Politti, F., Palomari, E. T., Barros-Filho, T. E. P., & De Camargo, O. P. (2011). Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle after spinal cord injury. Physiotherapy, 97(2), Reiner, A. (2015). The Brucker biofeedback method: A non-invasive therapy to improve gate of patients with cerebral palsy. A comparison of ambulant- and stationary therapy. Technische Universität München, München. van den Berg, F., & Cabri, J. (2007). Angewandte Physiologie (Bd. 3): Thieme. Weber, S. (2011). Effekte eines neuromuskulären Feedbacktrainings auf ausgewählte Parameter im "CPCHILD" Erhebungsbogen. Technische Universität München, München. 17

18 Appendix Table 1: Session : L/R upper abdominals Session Date: 2/25/2016 Session Time: 2:06:03 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Table 2: Session : L/R upper abdominals Session Date: 3/15/2016 Session Time: 3:55:03 PM Session Duration: 00:04: Segment Start Time: 00:00: Segment End Time: 00:00: Table 3: Session : back extension t4-t6 Session Date: 3/17/2016 Session Time: 3:28:32 PM Session Duration: 00:04: Segment Start Time: 00:00: Segment End Time: 00:00: Table 4: Session : back extension t4-t6 Session Date: 3/24/2016 Session Time: 3:02:39 PM Session Duration: 00:03: Segment Start Time: 00:02: Segment End Time: 00:02: Table 5: Session : back extension t6-t8 Session Date: 2/23/2016 Session Time: 1:45:02 PM Session Duration: 00:05:

19 Segment Start Time: 00:00: Segment End Time: 00:00: Table 6: Client: M Session : back extension t6-t8 Session Date: 3/24/2016 Session Time: 3:12:47 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Table 7: Session : back extension t8-t10 Session Date: 2/23/2016 Session Time: 1:50:08 PM Session Duration: 00:01: Segment Start Time: 00:00: Segment End Time: 00:00: Table 8: Session : back extension t8-t10 Session Date: 3/15/2016 Session Time: 3:13:16 PM Session Duration: 00:02: Segment Start Time: 00:01: Segment End Time: 00:02: Table 9: Session : back extension t10-t12 Session Date: 3/1/2016 Session Time: 3:28:19 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Table 10: Session : back extension t10-t12 Session Date: 3/15/2016 Session Time: 3:34:02 PM Session Duration: 00:02:

20 Segment Start Time: 00:01: Segment End Time: 00:02: Table 11: Session : knee extension sit-to-stand Session Date: 2/25/2016 Session Time: 1:51:49 PM Session Duration: 00:05: Segment Start Time: 00:00: Segment End Time: 00:00: Table 12: Session : knee extension sit-to-stand Session Date: 3/31/2016 Session Time: 3:19:06 PM Session Duration: 00:05: Segment Start Time: 00:01: Segment End Time: 00:02: Figure 1: Session : R elbow extension Session Date: 3/22/2016 Session Time: 3:54:23 PM Session Duration: 00:05: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 2: Session : R elbow extension Session Date: 3/22/2016 Session Time: 3:54:23 PM Session Duration: 00:05: Segment Start Time: 00:03: Segment End Time: 00:04: Figure 3: Session : R elbow extension Session Date: 3/31/

21 Session Time: 2:49:20 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 4: Session : R elbow extension Session Date: 3/31/2016 Session Time: 2:49:20 PM Session Duration: 00:03: Segment Start Time: 00:02: Segment End Time: 00:02: Figure 5: Session : R elbow flexion Session Date: 3/22/2016 Session Time: 4:01:19 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 6: Session : R elbow flexion Session Date: 3/22/2016 Session Time: 4:01:19 PM Session Duration: 00:03: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 7: Session : R elbow flexion Session Date: 3/31/2016 Session Time: 2:40:28 PM Session Duration: 00:04: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 8: Session : R elbow flexion Session Date: 3/31/

22 Session Time: 2:40:28 PM Session Duration: 00:04: Segment Start Time: 00:00: Segment End Time: 00:00: Figure 9: Session : R elbow flexion Session Date: 3/31/2016 Session Time: 2:40:28 PM Session Duration: 00:04: Segment Start Time: 00:01: Segment End Time: 00:02: