IV BOT_Advances in OT_Biofeedback_Dr. Punita V. Solanki_April 2024.pdf

Fourth (IV) Year BOT. Subject/Course: Advances in Occupational Therapy
S. No. 9: Adjunctive Therapies: Biofeedback
Lecture Notes by Dr. Punita V. Solanki. Professor & Incharge. April 2024
DYPU School of Occupational Therapy Nerul, Navi Mumbai. Dr. Punita V. Solanki Page 1 of 11
Course Syllabus: D Y Patil Deemed to be University School of Occupational Therapy
Bachelors of Occupational Therapy (BOT) Program 2021-2022
Year: Fourth (IV) Year BOT
Subject/Course: Advances in Occupational Therapy
Section (S. No.) 9: Adjunctive Therapies: Biofeedback
Contents (Hours: 02)
1. Definition of Biofeedback
2. Principles, Foundations and Elements of Biofeedback System
3. Neurophysiological Clinical Reasoning in Biofeedback System
4. Types of Biofeedback System and Clinical Applications with Advantages of Biofeedback
System as an Adjunct to Occupational Therapy
References
1. Willard and Spackman's Occupational Therapy by Elizabeth Blesedell Crepeau, Ellen S.
Cohn and Barbara A Boyt Schell. (By Helen L. Hopkins and Helen D. Smith: 8th
Edition
1993). 11th
Edition 2009 and 13th
Edition 2019.
2. Occupational Therapy for Physical Dysfunction by Catherine Trombly. 4th
Edition 1995,
5th
Edition 2002, 6th
Edition 2014. Chapter 19 Physical Agent
Modalities and Biofeedback Pages: 579-581.
3. Biofeedback: Principles and Practice for Clinicians by John V. Basmajian. 1st
Edition 1979
and 3rd
Edition 1989
4. Clinical Biofeedback: A Procedural Manual by Kenneth R. Gaarder and Penelope S.
Montgomery. 1st
Edition 1977
5. Occupational Therapy: Practice Skills for Physical Dysfunction by Lorraine Williams
Pedretti. 4th
Edition 1996, 5th
Edition 2001, 7th
Edition 2018
6. Therapeutic Exercises by John V. Basmajian. 5th
Edition 1990

Biofeedback Definition
The term “Biofeedback” is used to describe “External Psycho-Physiological Feedback”
Biofeedback may be defined as the technique of using equipment (usually electronic) to
reveal to human beings some of their internal physiological events, normal and abnormal, in
the form of visual and auditory signals in order to teach them to manipulate these otherwise
involuntary or unfelt events by manipulating the displayed signals.
Biofeedback may be used by occupational therapists to assist a patient in developing specific
sensorimotor skills and to improve movement in an occupational task. Biofeedback motivates
patients whilst informing them of success in changing joint position or contracting a muscle.
Biofeedback, which means biological feedback, refers to the process of using
instrumentation to feed back to the patient immediate information about what the body is
doing. Feedback is provided to the patient before the patient is even consciously aware of the
body’s action. This allows the patient to make small alterations in body functions during
performance in order to improve the actual functional outcome.
Biofeedback therapy trains the patient/client to control some physiological variable through
visual or auditory feedback. The objective is to reduce somatic arousal.
The Essential Components & Pre-Requisites of Biofeedback Training include:
1. Clear goals.
2. Proper instructions.
3. Feedback of information.
4. Enough time.
5. Practice for learning.
6. Adequate level of consciousness and cognitive understanding to participate in Biofeedback
training effectively.
7. Availability of the biofeedback training unit and an experienced and expert therapist who
are trained and certified in the use of the biofeedback device.

Feedback Framework Versus Operant Conditioning Framework
A: Biofeedback Apparatus
B: Operant Conditioning
Similarity of Biofeedback and Operant Conditioning
A: Biofeedback: an organism (1: usually a human being) is functioning in a setting (i.e.,
structured environment [2, 3, & 4]) where same particular behaviour or physiological variable
of the organism is picked up and carried (2) to a biofeedback apparatus (3) which measures
and processes it and, in some form, feeds back a signal derived from that behaviour or
physiological variable (4).
B: Operant Conditioning: an organism (1) is likewise functioning in a setting (a structured
environment [2, 3, &4]) where some particular behaviour of the organism is likewise picked
up and carried (2) to an apparatus, in this case a reinforcement apparatus (3) which measures,
processes and in the form of a reward or punishment feeds back information leading to what
is desired for the next step (4).
Clinical Reasoning and Foundations of Biofeedback
All of the work categorized as Biofeedback relies upon a simple idea: To provide
subjects/patients with information about what is going on inside their bodies. Given this
information, they have a chance to control the process about which the information is
provided, whereas without the information control would be impossible.
Biofeedback Apparatus
Organism
(Usually a Human Being)
3
1 2
4
Reinforcement Apparatus
Organism
1 3
2
4

This idea rests upon two principles:
1. Principle of feedback: of which biofeedback is a specific instance, while
2. Great truism of information theory: this principle of Ashby’s can best be stated as
follows: “A variable cannot be controlled unless information about the variable is available to
the controller”.
The idea of “feedback” is not only a foundation for biofeedback, it also leads into the study of
“Homeostasis” the major means by which the body maintains itself in health (Homeostatic
adaptive control systems mechanisms are feedback mechanisms).
Elements of a Biofeedback System
Biofeedback units have three major components to detect, measure, and report activity in the
body: the transducer, the processing unit, and the output mechanism.

Biofeedback Instrumentation: All biofeedback instruments have following components:
1. Signal Transducer
2. Signal Amplifier
3. Signal Processor and
4. Signal Output Display
1. Signal Transducer: detects the change in the parameter being measured. Different
transducers are used to pick up different types of signals. In general, there are 2 types of
signals monitored for biofeedback purposes:
i. The actual electrical signal produced by physiological processes in the body e.g., muscle
fibre depolarization. The transducers to pick up this biological signal are electrodes i.e., small
pieces of metal that convert ionic bioelectric current to electronic current. The electrodes are
taped to the patients’ skin over the muscle to detect the tiny electrical signals that skeletal
muscle generates during contraction.
ii. The other type of signal used for biofeedback purposes is the result of a mechanical or
chemical change of the transducer secondary to the change in the body. The
electrogoniometric transducer, the potentiometer, is a type of variable resistor that changes
resistance when rotated.
2. Signal Amplifier & 3. Signal Processor: contains electrical circuits that amplify
(enlarge), rectify (make all positive polarity), filter (smooth) and integrate (collect, store or
sum) the signal in preparation for its display. Different processing systems are required for
EMG Biofeedback which is an alternating current (AC) signal and Electrogoniometric
Biofeedback, which is a direct current (DC) signal.
4. Signal Output Display: The output of the feedback display changes instantaneously in
proportion to the effort to give the patient immediate information about his/her response.

The type of display can take many forms. For example:
1. Computer monitor on which the signal can be plotted over time
2. Sound broadcast over a speaker
3. Buzzers of various types
4. Lights or meters
Any type of appliance can be attached to the switching unit: radio, television, electronic toys,
tape player etc. A choice can be made between audio or visual displays by trial and error.
Biofeedback instruments have either a detector that requires the signal to reach a certain level
or threshold before the display is activated or a goal line on the computer display. This allows
shaping of the patients’ responses by requiring improvement to obtain the reward of the
display based on operant conditioning methodology.
Dual monitoring i.e., monitoring of one visual display (agonist) and one auditory display
(antagonist) can be used in cases where contraction of agonist and relaxation of antagonist
contraction of two synergistic muscles is desirable.
I. Electrogoniometric Biofeedback
An electrogoniometer is a biofeedback device similar to a goniometer but with electronic
components that directly inform the patient of joint positions during movement. Two types of
electrogoniometers are commonly used:
1. A Static Electrogoniometer: offers auditory or visual feedback when a target angle is
achieved (threshold feedback). The therapist determines the desired angle the patient is to
reach and sets the device to offer feedback when that angle is attained e.g., auditory feedback
such as buzzer or visual feedback such as light.

2. A Dynamic Electrogoniometer: offers constant visual feedback regarding change in joint
angle during movement (motion feedback) e.g., visual feedback is a computer monitor.
Treatment Applications
1. Threshold or Target Feedback using a static electrogoniometer if the goal is to increase
range of motion.
Training Method of Target Electrogoniometry
a. Determine active range of motion (AROM) goal for movement desired.
b. Set up target electrogoniometric device to provide feedback at desired goal.
c. Patient initiates movement until feedback from device is obtained.
d. Patient repeats movement as prescribed by the therapist for 10-15 minutes.
e. Target angle may be increased during session as the patient improves.
2. Motion Feedback: produced by a dynamic electrogoniometer is used to improve speed
and direction of movement.
Training Method for Motion Electrogoniometry
a. Set up dynamic electrogoniometric device to record desired joint movement.
b. Passively move patient’s limb to record the desired waveform on monitor. Pay attention to
both the extent and speed of motion. Start at a point where the patient can succeed.
c. Patient attempts to duplicate waveform produced by therapist’s passive movement.
d. Patient repeats movement as prescribed by the therapist for 10-15 minutes.

e. As the patient succeeds, change the waveform to upgrade the extent of motion, the speed of
motion or both.
II. Electromyographic (EMG) Biofeedback
EMG is a recording of the electrical activity produced by muscle fibres of activated motor
units. When a muscle contracts, the contracting motor units generate an electrical signal. The
EMG signal reflects the number and size of motor units contracting. This electrical activity
can be measured with needle or surface electrodes.
Electrodes
Needle electrodes penetrate the skin and are placed in close proximity to motor units. They
are used when the output of a specific, small or deep muscle is desired.
Surface electrodes are more commonly used because of their relative comfort and their non-
invasiveness.
Smaller electrodes are used for smaller muscles. Widely spaced electrodes are used to pick up
signals from larger surface and from deep muscles. Closely spaced electrodes are used to pick

up signals from more specific and superficial muscles. All electrodes require the use of a
conductive gel or cream to establish a uniform connection between the skin and the electrode.
EMG Biofeedback Device
EMG biofeedback unit consist of a central unit to which the electrode wires are connected for
signal processing. The central unit has controls to allow the therapist to set parameters such
as thresholds and type of output signal. The output signal may emanate from the central unit
or from a peripheral device attached to the central unit such as a computer monitor. An EMG
biofeedback displays readings in microvolts or millionths of a volt.
EMG devices use differential amplifiers and electrical filters, to eliminate electrical energy
from the environmental sources and display only electrical signals related to motor unit
activity. Both visual and auditory feedback can be used in the treatment sessions.
Anatomical Factors
The anatomical factors underlying the processing of information from the muscle feedback
systems are:
I. Afferent Component: Exteroceptive
1. Visual-Auditory
2. Cutaneous
3. Proprioceptors
4. Cerebellum
II. Efferent Component
1. Motor cortex
2. Other Efferent systems like descending pathways of brainstem
3. Basal ganglia
Treatment Applications
1. Muscle Re-education and Muscle Strengthening: EMG biofeedback is used to re-
educate weak or flaccid muscles and to strengthen weak or normal muscles.
Training Method
a. Begin with large, widely spaced electrodes over the muscle belly.
b. Initially set the threshold at an attainable level.

c. During a 10-15 minutes treatment session, the patient voluntarily contracts the muscle to
reach the threshold level.
d. When possible, incorporate purposeful activities to facilitate the muscle activity desired.
e. Gradually raise the threshold during the treatment session to challenge the patient to
contract the muscle more strongly.
2. Decreasing Spasticity: EMG biofeedback is used to decrease spasticity by relaxing the
targeted muscle.
Training Method
a. Begin with small, closely spaced electrodes over the muscle belly.
b. Initially set the threshold at an attainable level.
c. Place the limb in midrange and keep the environment free of distractions.
d. During a 10-15 minutes treatment session, the patient attempts to maintain relaxation of the
muscle below the threshold level.
e. Gradually decrease the threshold as the patient learns to relax the muscle.
f. In subsequent sessions, challenge the patient to maintain relaxation of the spastic muscle
while contracting the antagonistic group of muscles.
3. Control over Urinary Incontinence: may be treated by EMG biofeedback by assisting a
patient to gain control over the pelvic floor muscles.
Other Areas where Biofeedback may be used are:
1. Pain management in headache disorders, low back pain, arthritis, myofascial pain, and
complex regional pain syndrome (CRPS), phantom limb pain following amputation.
2. General relaxation for stress management (via body temperature and heart rate regulation).
3. Improve control of gastrointestinal motility.
4. Monitoring during pregnancy and labour.
5. In cardiovascular disorders to gain control over supraventricular arrhythmias, high blood
pressure etc.
6. In psychotherapy for emotional, behavioural and psychosomatic disorders by peripheral
skin temperature biofeedback and galvanic skin response training used to treat emotional
disorders such as phobias, anxiety and stuttering. This technique is also used as a relaxation
technique.

7. In fear and anxiety (via cognitive appraisal and stress response system regulation), and
attending behaviour (via regulation of brain wave states that promote focused attention).
Advantages of Electronic Bio-Feedback as an Adjunct to Occupational Therapy
1. It is a natural extension of the use of verbal feedback (cues) generally given by the
therapists during the treatment sessions to motivate the patients/clients and to correct them by
spotting.
2. The feedback information is objective and can be monitored and controlled by the
patient/client.
3. It provides accountable documentation of the patients/clients’ treatment progress and
assists in objective recording of progress notes.
4. It is used in preparation for or concurrently with purposeful and occupation-based
activities. The goal is always eventual effective and timely engagement in occupation.

IV BOT_Advances in OT_Biofeedback_Dr. Punita V. Solanki_April 2024.pdf

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