The Effect of Electromyographic Biofeedback Treatment

in Improving Upper Extremity Functioning of Patients

with Hemiplegic Stroke

an-Aslan, MD, Guldal Funda Nakipog

lu-Yuzer, MD,
Meryem Dog
zgirgin, MD
_

an, MD, Ilkay
Asuman Dog
Karabay, MD, and Nese O

This study evaluated the effect of electromyographic biofeedback (EMG-BF) treatment

on wrist flexor muscle spasticity, upper extremity motor function, and ability to perform activities of daily living in patients with hemiplegia following stroke. A total of
40 patients were enrolled and were randomly assigned to two groups: a group treated
with EMG-BF (study group) and a untreated (control) group. Both groups participated
in a hemiplegia rehabilitation program consisting of neurodevelopmental and conventional methods and verbal encouragement to relax spastic wrist flexor muscles. In
addition, the study group received 3 weeks of EMG-BF treatment, 5 times a week,
for 20 minutes per session at hemiplegic side wrist flexors. Clinical findings were assessed before and after rehabilitation using the Ashworth scale (AS), Brunnstroms
stage (BS) of recovery for hemiplegic arm and hand, the upper extremity function
test (UEFT), the wrist and hand portion of the Fugl-Meyer scale (FMS), goniometric
measurements of wrist extension, surface EMG potentials, and the Barthel Index
(BI). There was no statistically significant difference between the two groups in terms
of age, sex, systemic disease, and the etiology, side, and duration of hemiplegia. There
also was no statistically significant difference in the pretreatment values between two
groups. We found statistically significant improvements posttreatment in the AS, BS,
UEFT, goniometric measurements of wrist extension, and surface EMG potentials in
the study group. We also noted statistically significant differences in the wrist and
hand portion of the FMS and the BI in both groups, but with significantly greater improvements in the study group. Our findings indicate a positive effect of EMG-BF
treatment in conjunction with neurodevelopmental and conventional methods in
hemiplegia rehabilitation. Key Words: Electromyographic biofeedbackdupper
extremity functiondhemiplegiadrehabilitation.
2012 by National Stroke Association

Stroke is a frequent cause of neurologic disability. The

growing proportion of elderly persons in the population
is making stroke prevention and treatment of increasing

From the Department of 5th Physical Medicine and Rehabilitation

Clinic, Ankara Physical Medicine Rehabilitation Education and
Research Hospital, Ankara, Turkey.
Received March 30, 2010; accepted June 20, 2010.
Address correspondence to Meryem Do

gan-Aslan, MD, Hanmeli
sok. 26/5 Shhye, Ankara, Turkey. E-mail: meryemdoganaslan@
yahoo.com.
1052-3057/$ - see front matter
2012 by National Stroke Association
doi:10.1016/j.jstrokecerebrovasdis.2010.06.006

importance worldwide.1 Cerebrovascular diseases entail

long-term hospitalization and expensive care, posing
medical, financial, and social challenges. In the rehabilitation of patients with hemiplegia caused by a cerebrovascular accident (CVA), the goals are to decrease and
prevent complications, enable the patient to reach his or
her maximum functional capacity as soon as possible,
and make him or her as independent and productive as
possible.2
Spasticity is a common impairment following stroke,
typically resulting in functional loss.3 It can cause reduced flexibility, inpaired posture, and decreased functional mobility, as well as joint pain, contractures, and
difficulty in positioning for comfort and hygiene.4 Clearly,

Journal of Stroke and Cerebrovascular Diseases, Vol. 21, No. 3 (April), 2012: pp 187-192

187



M. DOGAN-ASLAN
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188

the rehabilitation of patients who had developed hemiplegia after a CVA.

upper extremity function is of crucial importance to hemiplegic patients ability to perform activities of daily living
(ADL).
The functional loss in the affected upper extremity
following hemiplegia leads to significant problems.5 Conventional treatment approaches are not always successful
in restoring upper limb function, and new techniques or
combination therapies for treating the hemiplegic upper
limb are needed.6
Electromyographic biofeedback (EMG-BF) is becoming
increasingly important in rehabilitation. EMG-BF can be
described as a scientific method that warns a patient about
his or her own muscle activity by increasing myoelectric
signals coming from the muscles and converting these
signals to visual and/or auditory signals. This allows the
patient to control and regulate this muscle activity, which
is not controllable under normal conditions.6-10 The aim
of the present study was to evaluate the effectiveness of
EMG-BF in decreasing wrist flexor spasticity and regaining hand function and the ability to perform ADL during

Patients and Methods

Out of the 80 patients who had developed hemiplegia
due to a CVA and were included in our inpatient hemiplegia rehabilitation program, we selected 40 patients who
were cooperative, sufficiently motivated, willing to participate, had no hearing or vision problems, had developed
sitting balance, and had no serious systemic disease. We
excluded 19 patients from the study, 17 because they did
not meet the inclusion criteria and 2 because of refusal to
participate. A total of 61 patients were enrolled in the
study, but 21 did not complete the study due to systemic
social problems and other reasons (Fig 1). For each patient,
age, sex, etiology of hemiplegia, hemiplegic side, duration
of hemiplegia, and any systemic diseases were recorded.
The 40 patients were randomly divided into two groups,
the study group and the control group. The patients in both

Assessed for eligibility of

hemiplegic patients (n=80)

Excluded (n=19)
Not meeting inclusion criteria
(n=17)
Refused to participate
(n= 2)
Other reasons
(n= 0)

Enrollment
They were randomized

Study Group (n=30)

Control Group (n= 31)

EMG Biofeedback+Neurodevelopmental
and conventional therapy(n=26)
Did not receive EMG
Biofeedback+Neurodevelopmental and
conventional therapy (n=4) (Because of
the developed systemic problems)

Lost to follow-up (n=2)

(Because of the developed
social problems)
Discontinued treatment (n=1)
(Because of the developed
recurrent CVA attack)

Allocation

Follow-Up

Analyzed (n= 23)

Excluded from analysis (n=3)
(Because of the missing data)

Neurodevelopmental and conventional

therapy(n=26)
Did not receive Neurodevelopmental
and conventional therapy (n=5)
(Because of the developed systemic
problems)

Lost to follow-up (n=3)

(Because of the developed
social problems)
Discontinued intervention(n=2)
(Because of the developed
recurrent CVA attack)

Analyzed (n= 21 )
Analysis

Excluded from analysis (n= 1)

(Because of the missing data)

Figure 1. Flowchart of patients enrolled

in the study.

EMG BIOFEEDBACK TO IMPROVE UPPER EXTREMITY FUNCTION IN HEMIPLEGIA

189

Table 1. Demographic data

Mean Age, years,

Sex, n (%)
Female
Male
Hemiplegic side, n (%)
Right
Left
Etiology of hemiplegia, n (%)
Thromboemboli
Hemorrhage
Duration of hemiplegia, days,
Systemic disease, n (%)

Study group

Control group

57.90 6 13.32

60.75 6 12.81

..05

9 (45%)
11 (55%)

7 (35%)
13 (65%)

..05
..05

10 (50%)
10 (50%)

12 (60%)
8 (40%)

..05
..05

13 (65%)
7 (35%)
199.30 6 222.33
18 (90%)

13 (65%)
7 (35%)
145.40 6 149.97
18 (90%)

..05
..05
..05
..05

group received spasticity treatment involving neurodevelopmental methods, conventional methods, and verbal encouragement to relax spastic wrist flexor muscles. The
study group also received 3 weeks of EMG-BF treatment
(consisting of five 20-minute sessions per week) applied
to the spastic wrist flexor muscles on the hemiplegic side.
Before and after treatment, the following scales were
used to assess hand and hand wrist activity: the Ashworth
scale (AS) for evaluating upper extremity spasticity; Brunnstroms stage (BS) of recovery for the hemiplegic arm and
hand, for evaluating upper extremity and hand motor function; the upper extremity function test (UEFT), and the
wrist and hand portion of the Fugl-Meyer Scale (FMS) of
functional assessment11-14 Goniometric measurements of
active range of motion of wrist extension (WE-AROM)
and EMG-BF electrical muscle activity measurements
were recorded before and after treatment. The ability to
perform ADL was evaluated using the Barthel Index
(BI).15
Before and after treatment, the control and study group
patients were evaluated using the spasticity and functional scales by an individual researcher unaware of
group assignment.
EMG-BF treatment was administered using the Elettronica Pagani Italy Modular BFB biofeedback device
(Elettronica Pagani Medical Devices/Paderno DugnanoMilano-Italy). During treatment, the patient was seated
in a comfortable position next to the device in a quiet
room with the wrist on a pillow at 90-degree flexion. Electrodes were applied to the wrist flexor motor points on
the forearm. The patients muscle activity was shown on
a computer monitor as auditory and visual signals.
The device sonically warns the patient of increased muscle activity. The patient was instructed to try to maintain
the muscle activity on the isoelectric line. The patients motor unit potentials were monitored, and periodic verbal
feedback was provided.
Statistical analysis of the data was performed using
SPSS version 9.00 for Windows (SPSS Inc, Chicago, IL).

Descriptive analysis, the Student t test, the c2 test, the

sign test, Wilcoxons signed-rank test, and the MannWhitney U test were used for evaluation.

Results
The general features of the study and control groups
are presented in Table 1. There were no statistically significant differences between the groups in terms of age, sex,
systemic disease, and side, etiology, and duration of
hemiplegia. The pretreatment BS score of recovery for
hemiplegic arm and hand values and the AS scores of
wrist flexor spasticity did not differ significantly between
the two groups (P ..05). However, there was a significant
difference between the posttreatment BS and AS scores of
the study and control groups (P , .05), with higher posttreatment BS values and more markedly decreased AS
scores in the study group (Table 2).
There was no significant difference between the groups
in pretreatment UEFT values and WE-AROM goniometric
values (P . .05). However, there was a significant difference between the posttreatment UEFT values and WEAROM goniometric values in the study group (P , .05),
but not in the control group (P . .05). These findings also
support the efficacy of EMG-BF treatment (Table 3).
The Bonferroni-corrected Student t test was used to evaluate the EMG-BF muscle activity measurements of the
study and control groups. The significance limit was set
at 0.025. There was no significant difference in pretreatment EMG-BF muscle activity values between the two
groups (P ..025). There was a markedly significant difference between the posttreatment values in the study group
(P ,.001), but not in the control group (P ..025) (Table 3).
There was no significant difference in the pretreatment
FMS wrist and hand values and BI values between the
study and control groups (P . .05). However, there was
a significant between-group difference in posttreatment
FMS and BI values, in favor of the study group (75.50 6
14.04 vs 53.75 6 24.33) (Table 3).



M. DOGAN-ASLAN
ET AL.

190

Table 2. Pretreatment and posttreatment Ashworth (Ashw) scale scores of wrist flexor spasticity and BS of recovery for hemiplegic
hand assessment of the study and control groups
Pretreatment

Ashw 1
Ashw 2
Ashw 3
BS 1
BS 2
BS 3
BS 4
BS 5

Study group

Control group

1 (5%)
12 (60%)
7 (35%)
9 (45%)
2 (10%)
4 (20%)
4 (20%)
1 (5%)

4 (20%)
9 (45%)
7 (35%)
9 (45%)
2 (10%)
3 (15%)
5 (25%)
1 (5%)

Posttreatment
P

..05

Discussion
The aim of our study was to evaluate the effect of EMGBF treatment on upper extremity spasticity, hand function,
and ability to perform ADL during the rehabilitation of
patients with hemiplegia due to CVA. Biofeedback is
a simple, noninvasive, painless treatment method with
no side effects. EMG-BF can be used in concert with various clinical approaches aimed at increase cognitive and
sensorimotor performance to relax hyperactive muscles
and to recover muscle strength. Increased data transfer to
the functional area of the affected extremity in the central
nervous system of hemiplegic patients increases neuroplasticity. EMG-BF treatment stimulates and reinforces
neural connections in the motor cortex and promotes
more permanent effects by increasing cortical activity.9,16,17
Neurodevelopmental approaches, EMG-BF treatment,
and functional electrical stimulation (FES) have proven
to be as beneficial as conventional methods for neuromuscular reeducation in spasticity treatment. Some studies
have reported better results with EMG-BF compared
with conventional methods.16
In the present study, there were no statistically significant differences between the study and control groups in
terms of patient age and sex; systemic disease; side,

Study group

Control group

12 (60%)
8 (40%)
0 (0)
1 (5%)
4 (20%)
6 (30%)
4 (20%)
5 (25%)

4 (20%)
8 (40%)
8 (40%)
8 (40%)
2 (10%)
4 (20%)
5 (25%)
1 (5%)

,.05

etiology, and duration of hemiplegia; and pretreatment

values of the various assessment tools. We found statistically significant posttreatment improvements in AS, BS,
UEFT, WE-AROM, and EMG-BF muscle activity values
in the study group, but not in the control group. We also
found statistically significant differences in FMS and BI
values in both groups, but with significantly greater
improvements in the study group.
EMG-BF treatment was first used by two investigators
in 1960 for neuromuscular reeducation of a hemiplegic
upper extremity. They reported a 20% recovery of upper
extremity function following a 1-hour session.10,18 Wolf
and Binder-Mcleod8 reported decreased spasticity in
patients receiving EMG-BF treatment; improvement in
fine hand movements was particularly evident. They
also reported an increase in assistive functional capacity,
although some patients did not recover the ability to
grasp. Lourencao et al16 applied occupational therapy
(OT) plus FES and EMG-BF to one group and only OT
and FES to another group and found better recovery in
the former group, with decreased spasticity and increased
upper extremity function. We also found a significant decrease in wrist spasticity values of the study and control
groups after EMG-BF treatment, with a more marked
decrease in the study group.

Table 3. Pretreatment and posttreatment UEFT values, score on the wrist and hand portion of the FMS, goniometric measurements
for WE-AROM, EMG-BF values, and BI scores for the study and control groups

UEFT
FMS
WE-AROM
EMG- BF, mV
BI

Study group
Control group
Study group
Control group
Study group
Control group
Study group
Control group
Study group
Control group

Pretreatment

Posttreatment

0.40 6 0.82
0.45 6 0.94
2.40 6 3.06
2.10 6 3.07
0.50 6 2.23
1.50 6 6.71
288.68 6 68.09
262.50 6 38.53
44.50 6 11.45
43.75 6 22.70

1.20 6 1.39
0.50 6 0.94
6.90 6 6.34
3.20 6 4.23
13.25 6 20.92
2.50 6 7.16
233.42 6 15.04
263.91 6 44.71
75.50 6 14.03
53.75 6 24.32

,.05
..05
,.001
,.05
,.05
..05
,.001
..025
,.001
,.001

EMG BIOFEEDBACK TO IMPROVE UPPER EXTREMITY FUNCTION IN HEMIPLEGIA

19

Turczynski et al reported recovery of gross motor

function in the hand and arm at a subjective global evaluation level, along with decreased shoulder and body
movements that support the upper extremity. Balliet et
al20 studied sensory biofeedback treatment in patients
with chronic hemiplegia and disturbed auditory perception. These patients, who had derived no benefit from
previous treatment and had even stated that they would
prefer amputation, were able to use their upper extremities for rough assistance after 50 treatment sessions.
Basmajian et al21 studied behavioral therapy plus
EMG-BF treatment in one group and the applied Bobath
neurodevelopmental treatment method in another
group. They found marked improvement in UEFT values
in both groups, but better recovery in the group treated
with EMG-BF. In an another study, Kraft et al22 distributed patients into 4 groups and compared the effects of
EMG-BF, electrostimulation, and proprioceptive neuromuscular facilitation techniques. After 3 months of
treatment, the EMG-BF group demonstrated the most
significant recovery.
In the present study, we used conventional neurodevelopmental methods and verbal encouragement to relax
spastic wrist flexor muscles in both groups, with audiovisual EMG-BF treatment provided only to the study group.
Motor and functional evaluation showed significant development in the BS and UEFT values in the study group,
but not in the control group. Both groups demonstrated
significant improvement in hand and wrist function according to the FMS; however, the study group had higher
FMS values compared with the control group.
Inglis et al10 found better recovery in a study group that
received EMG-BF, based on Brunnstrom neurophysiological evaluation and active ROM. These authors then
applied a 20-session EMG-BF treatment to the control
group and observed increased muscle strength and active
ROM values in that group as well. Rathkolb et al23 applied EMG-BF treatment to the hand and wrist of hemiplegic patients and found recovery of EMG muscle
activity in 78.1% of the patients. Armagan et al6 applied
a treatment involving the Brunnstrom neurophysiological
approach in two groups, along with EMG-BF treatment in
one of the groups and placebo EMG-BF treatment in the
other. Although tatistically significant improvements
were seen in both groups, the group that received EMGBF demonstrated better active ROM and EMG-BF muscle
activity measurements.
In the present study, we found a significant increase in
WE-AROM in the study group, but not in the control group.
The foregoing findings indicate that in general, even in
patients with chronic hemiplegic, EMG-BF can decrease
upper extremity spasticity, develop motor function, and
increase joint movement range and muscle activity.
EMG-BF can have important benefits when applied either
independently or in conjunction with conventional and
neurodevelopmental or electrical stimulation methods.

191

We also evaluated the effect of EMG-BF on the ability to

perform ADL. Although both the study group and the
control group demonstrated significantly higher BI scores
compared with pretreatment values, the improvement
was greater in the study group.
Wissel at al24 reported that the chance of long-term
success of biofeedback treatment is enhanced when patients
are able to apply the learned activities to their daily life.
Wolf et al9 concluded that sensorimotor integration can be
learned after noting continued functional improvement,
as well as persistent efficacy of EMG-BF, over a 1-year
follow-up in their patients given EMG-BF. Lourencao
et al16 reported progressively increasing functional capacity
and improving voluntary movement control with EMG-BF
treatment.
In the present study, we did not plan to evaluate
whether the functional improvement persisted during patient follow-up. More meaningful long-term follow-up
studies are needed to evaluate whether the improvements
in spasticity and function from EMG-BF persist or fade
over time.
Some studies have reported results calling into question the efficacy of EMG-BF. For example, Hemmen and
Seelen17 applied EMG-BF treatments to one group and
conventional electrostimulation treatment to another
group, and found no difference between the two groups
at baseline and at 1-year follow-up. Bate and Matyas25
found very little change in EMG in a group receiving
EMG-BF and a group not receiving EMG-BF, and noted
significantly improved active movement in both groups.
The group without EMG-BF actually showed better
development of fast movement.
Regardless of the foregoing studies, our findings and
those of some previous meta-analyses indicate benefits
of EMG-BF. For example, in a meta-analysis of 9 controlled
biofeedback treatment studies conducted between 1966
and 1991 and including a total of 192 hemiplegic patients,
Schleenbaker and Mainous26 concluded that biofeedback
effectively produced neuromuscular reeducation. The
other meta-analyses, Moreland and Thomson27 found
that EMG-BF was more effective than conventional physical treatment approaches in improving upper extremity
function following CVA. However, after a systematic literature search and analysis of 26 randomized controlled trials, Van Dijk et al28 found no positive effect of augmented
feedback in improving motor function of the upper extremity in patients in rehabilitation. In another analysis
of a small number of individual studies, Woodford and
Price29 suggested that EMG-BF plus standard physiotherapy produces improvements in motor power, functional
recovery and gait quality compared with standard physiotherapy alone, combination of all the identified studies did
not find a treatment benefit.
Various investigators have stated that a high degree of
motivation is an important factor to obtain the maximum
positive results with EMG-BF treatment.16 We provided

192

encouraging verbal feedback to help focus the patients

attention and increase motivation. According to the motor
education theory, regaining control over the movement
and transfer phases requires that the patient have information on the movement that he or she is performing in
order to learn about the motor response. Biofeedback
can help facilitate the process of consolidation of information.30
In summary, our findings demonstrate that EMG-BF in
concert with neurodevelopmental and conventional
techniques for upper extremity rehabilitation in patients
with hemiplegia due to CVA can effectively decrease
spasticity, improve motor skills and functional use of
the hand, and improve the ability to perform ADL.
EMG-BF is a valuable technique to increase the effectiveness of the various therapeutic exercises involved in the
rehabilitation of hemiplegia.

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