It's about biofeedback - a new experience in physical therapy
by Vicki Pollyea, OT, FL. U.S.A.

I was excited and a little anxious about seeing the new physiatrist, or physical medicine specialist. I was curious if she had any new ideas or suggestions to keep my old muscles working. So I felt some concern when she recommended physical therapy. Although I am a firm believer in the power of therapy, I have had a few bad experiences in therapy ...was this time going to be the same?

Let me share a little of my history and why I was anxious about the new referral. A few times over the past 20 years, I had been referred to physical therapy for evaluations and muscle strengthening: something that often happens when one has CMT. Almost every time I worked with an eager and very positive therapist who was sure that with hard work we could make me stronger. However, each time I experienced severe consequences from that hard work. The motto was work till it hurts, and boy did it hurt, often with disastrous consequences. Now we understand the importance of strengthening muscles without fatiguing them. For people with CMT the motto "no pain, no gain" just does not apply.

No matter how many times I tried to explain to therapists how easily my muscles fatigued, they were always sure that their program would be great. Usually I would quit the program as the fatigue and pain were debilitating. What was going to be different this time? How would I explain to the new therapist the problems I had encountered in the past? I am very excited to share with you that this time it was different. What made the difference this time? This time I worked with a therapist who listened to me and she utilized a new tool ...biofeedback!

Biofeedback has been around for many years. It involves using a machine to give you feedback about how the muscle is working. It is used in many ways including helping learn relaxation techniques, re-educating muscles and now for evaluating and strengthening muscles.

Through conversations with physical and occupational therapists I know, I had heard that biofeedback might be beneficial to my situation. After the doctor prescribed physical therapy, I contacted a large teaching hospital in my area. They referred me to the rehabilitation center where I was referred to a physical therapist who utilized biofeedback for evaluation and strengthening. After only one session I was very pleased and intrigued how this tool might help me.

First let me try to explain the process. Sticky electrode pads are placed over the belly of a superficial muscle. These pads like EKG electrodes, involve no needles and the only pain is the glue sticking to your hair. The pads are then connected via cords to the biofeedback machine which is connected to a computer with a large screen. The electrodes sense the electrical activity in the muscle when it fires, and sends the information to the computer for processing. It then shows on the screen as the amount of electrical activity expressed in microvolts in the muscles. This indicates the strength of the muscle. This machine is so sensitive that it can sense electrical muscle activity even in a muscle that is too weak to cause any movement. By watching the screen one gets "feedback" when the muscle is activated, and when it is at rest. It shows how certain muscles are working together for an action, or if the muscles are working against each other. It also shows when a muscle is getting tired before one can even sense the fatigue. So by watching the chart of muscle activity, one can evaluate the strength, durability, and function of the muscle.

For me the evaluation process took many sessions as only four muscles at a time can be evaluated. For example, during one session my quadriceps and hamstrings (the large thigh muscles) on both legs were evaluated. The muscles were evaluated during movement such as extending my knee, during resistance, and during an activity such as rising from and sitting back in a chair.

So what did I learn during this evaluation? In very objective terms I learned how quickly my muscles fatigue. I always knew that my "strength gave out" quickly but with biofeedback we were able to document that my strength decreased nearly 50% with only 5 repetitions. This is a very dramatic fatigue. It helps explain why when the physicians test my muscles they test fairly strong but I have great difficulty doing repetitive actions, or sustained muscle contraction such as holding a pot when cooking.

I was also very surprised to learn how weak many of my muscles are especially the proximal muscles of my legs (the thigh and hip muscles). It was very dramatic for me to see that many of my muscles only fired in the range of 20-80 microvolts when the normal range is 200 up to 400 microvolts. For some unknown reason, one of my strongest muscles was in the distal part of my legs which according to the literature about CMT should have been the weakest. This once again documented that CMT results in no set pattern of weakness.

Biofeedback also documented the difference in strength between my right and left sides . When the evaluation was complete I had pages of graphs showing the major muscles in my lower extremities doing isolated movements, and coordinated activities such as walking and sitting.

The evaluation gave me valuable information about how my muscles work together and against each other when I do movements. Since my quads are so weak, my hamstrings try to help out by also firing. The problem is that the hamstrings' action is antagonistic or the opposite of the quads' action. The result is the hamstrings are pulling against the quads which makes it even harder for the quads to do their work. This explains why when I walk it feel like I am trudging through mud. No wonder I get so tired!

Currently I am working on strengthening my muscles and learning new ways for my muscles to work together utilizing the feedback of the colorful screen.

When I am doing resistive strengthening activities, I immediately see how much the muscle is working. Also, I can see when the muscle is fatiguing before I sense it so I know when to take a break or even when it is time to stop that exercise. I am learning how to make gains without pain.

The biofeedback is also helping me learn better ways to do actions. For example, I am working on rising from a chair using more efficient muscles rather than the relying on the wrong muscles which tend to want to help out. I am also working in improving my balance by learning how to utilize the correct muscles during an activity. Last week the therapist told me "work those quads" during a weight shifting exercise. I thought that I was but when I looked at the screen, I saw that there was no activity in the quads.

By trying different ways of moving and closely watching the screen I was a able to see when my quads were firing and then I was able to modify my movement pattern.
This has been a very slow process. The evaluation took many sessions and now I am proceeding very slowly with the strengthening. For the first time, I am not experiencing severe pain and fatigue during PT. We are also seeing some improvement in strength of a few muscles. It is not a dramatic improvement but there is some, which makes the effort rewarding.

Although physical therapy is very easy to find, I am not sure of the availability of therapists who utilize biofeedback for muscle strengthening and re-education. It seems to be a new form of treatment using a tool that has been around for a long time. For your information, my therapist uses a Neuro Educator II. If you are interested in pursuing this therapeutic technique, contact your teaching hospital or large rehabilitation center and ask specifically if any physical or occupational therapists utilize biofeedback for muscle evaluation and strengthening .

After years of frustration with therapy, I am very pleased with my results utilizing biofeedback in physical therapy. I have learned valuable information about my strength, and especially the effect of fatigue on my activity. I am learning better ways to perform activities so that I can continue to be as active as possible. I am also very encouraged that for the first time I am experiencing improvements in my strength and functional capacity.

I'd like to thank Barbara Lambos, RPT, for her support, guidance, and assistance in editing this article.