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EMG Biofeedback

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Rachael Cuellar

on 24 March 2014

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Transcript of EMG Biofeedback

EMG Biofeedback
Jamie Cover, Rachael Cuellar, Lainey Estes
Stroke
EMG Biofeedback


Increase muscle activity (re-educate)
Decrease muscle activity (relaxation)
EMG Signal Processing
Common Mode Elimination


Reads muscle activity via ion flux – measured in μVolts

Uses two channels (3 electrodes)

Electrodes are placed parallel to muscle fibers (picks up more motor units this way; motor units enter perpendicular to the fibers)

Used as a teaching tool

Eliminates electrical activity that is common to both channels (power lines, electrical noise)

Band Pass Filters
Allows certain range of frequencies through (ex. muscle activity takes place between 20-300 Hz)
Cut out specific frequencies (usually 59-61Hz,
wall current is 60Hz)
In the Clinic
Uses skeletal muscle signals

Gives visual and/or audio feedback to patients

Patient uses this information to increase or decrease muscle activity
Sensitivity -
adjusted to match patients recruitment
capabilities
Threshold -
a set level that the patient must meet or exceed and will determine how sensitive the device
is
As sensitivity increases, threshold goes down
Quizita Time !!!!
When placing electrodes over the frontalis, one
should place the electrodes ___________
because the fibers run _____________.
A. On the floor; too fast
B. Lengthwise; too slow
C. Lengthwise: lengthwise
D. Diagonal; in an oblique axis
And the answer is...
C
A filter that only allows frequencies within a
given range, say 20-300Hz is know as:

A. Coffee filter
B. Air filter
C. Band pass filter
D. Common mode elimination filter
Drum roll please....
C
Greater sensitivity is:
A. A quality women look for in men
B. The proportion of actual positives which
are correctly identified
C. All of the above
D. Used for smaller and/or weaker muscles
D
When doing muscle re-education on Burke’s weak and
small Biceps brachii, as Burke gets stronger, one would turn the threshold _______, or sensitivity_________.

A. Off; off
B. Up; down
C. Down; Burke is not getting any stronger
D. Down; down
B !!!
The Effect of Electromyographic Biofeedback Treatment in Improving Upper Extremity Functioning of Patients with Hemiplegic Stroke
Task-Oriented Biofeedback to Improve Gait in Indivituals with Chronic Stroke: Motor Learning Approach
Effects of movement imagery and electromyography-triggered feedback on arm-hand function in stroke patients in the subacute phase
“In EMG-triggered feedback, the patient is asked to imagine dorsiflexing his or her wrist on the paretic side. It is assumed that this causes some initial muscle activity, and that when this is detected by EMG electrodes, amplified and presented to the same muscle, it elicits a genuine contraction of the wrist extensors.”


“Evaluated the effect of movement imagery-assisted EMG-triggered feedback stimulation of the wrist extensors on the paretic side of subacute stroke patients on the arm-hand function compared with conventional electrostimulation.”


27 patients with first ever, ischaemic, subacute stroke


Subjects
Inclusion criteria
Central paresis of the arm/hand after a first ever stroke

Post-stroke period greater than 3 weeks

Active wrist muscle strength between grade 2 and 3 on the MRC scale

Fair cognitive level

No additional severe rheumatologic, neurological or orthopaedic problems prior to the stroke

No pacemaker or severe cardiopulmonary complications

No history of epilepsy
Single-blinded

Longitudinal

Multicentre randomized controlled trial

Measures were take 54 days post stroke, 3 months later, 12 months post baseline

Intervention was carried out five days a week, for 12 weeks, for 30 minutes a day

Assigned to 2 groups by block randomization

Experimental group received EMG-triggered feedback therapy in addition to usual therapy

Reference group received conventional electrostimulation in addition to usual therapy

Design

• Upper extremity part of Brunnstrom Fugl-
Meyer test
• Action Research Arm test
Measures
Results
• During training, Brunnstrom Fugl-Meyer scores
improved 8.7 points
• Action Research Arm scores improved by 19.4
points
• P < 0.0001
Conclusion
EMG-triggered feedback stimulation did not lead to more arm-hand function improvement relative to conventional electrostimulation
Clinical Relevance
EMG-triggered feedback is an option, but is not better than conventional electrical stimulation
PEDro Score
5/10
“Evaluated the efficacy of EMG-BF applied in a task-oriented approach based on principle of motor learning to increase peak ankle power of the affected leg and gait velocity in patients with chronic mild to moderate hemiparesis.”
Subjects
20 participants
Inclusion Criteria
At least 6 months post stroke
Could walk 10m without aid
Capable of a minimal muscle contraction of the triceps surae to produce a feedback signal
Had some deficit of recruitment of triceps surae

Exclusion Criteria
Second stroke
Post stroke complications
Cognitive impairment
Visual or auditory deficits

Design
Consecutive convenience sampling

Randomly assigned to EMG-BF group (involved triceps surae) or control group

Fading frequency of BFB application and increasing variability in gait activities

20 treatment sessions, 45 minutes each, at least 15 minutes of walking related therapy for control group

Phase one: constant BFB and verbal instruction

Phase two: variable practice paradigm was applied with intermittent EMG-BFB

Phase three: BFB was mostly withdrawn, practice was variable

Control group received usual rehabilitation care (neurodevelopment, neurofacilitation techniques, task specific training, and/or task-oriented training)

Measures
Quantatative gait analysis was performed before, after treatment, and 6 weeks after post-gait analysis
Results
BFB treatment lead to significant increases in peak ankle power at push-off (P < .01)

Increase in velocity

Increase in stride length

No changes in the control group

Conclusion
“A task-oriented BFB treatment was effective in increasing peak ankle power, gait velocity, and stride length in a population with hemiparesis.”
Clinical Relevance
An increase in gait velocity can change a household walker to a limited community walker, or a limited community walker to a full community walker

The study used a limited sample of individuals and the findings might not be generalizable

PEDro Score
7/10
Biomechanical assessments of the effect of visual feedback on cycling for patients with stroke
“The aim of this study was to investigate the effect of visual feedback on the control of cycling motion in stroke patients from kinesiological, kinematic and kinetic aspects.”

“Providing visual feedback of cycling cadence could lead to improve task performance such as cycling smoothness and muscle activation patterns”

Subjects
40 participants
Inclusion Criteria
Unilateral brain lesion due to stroke

Having some voluntary movement control over affected lower limb

Maintain sitting for more than 30 minutes at a time

Exclusion Criteria
Histories of more than one stroke

Neurological disease

Acute lower limb orthopedic conditions that could affect cycling performance

Blindness or severe visual impairments

Sever cognitive impairments

Design
Cycling performance was analyzed with and without visual feedback

Surface EMG recording unit was used to measure muscle activation patterns of Rectus femoris and Biceps femoris

The experimental group was instructed to cycle at a cadence of 50rpm using visual feedback which was displayed on a computer screen located 120cm in front of the subject.

The control group was instructed to cycle the way they did in practice.

Measures
Cycling performance based on cycling EMG, Cycling cadence, and torque

Shape Symmetry Index (SSI) was used to describe similarity between the EMG linear envelope of the two legs; the higher the SSI, the better the symmetry, with a maximum value of one

Area symmetry index (ASI); represents the symmetry in the EMG magnitude

Cycling cadence

Roughness index (RI) : when a steady instantaneous cadence is maintained through the pedaling cycling, the RI will approach to zero

Average cycling power (Pav) ; the product of cadence and torque

Results
Significance level was set at p < .05
Conclusion
ASI increases in Rectus femoris

RI was decreased

Pav was increases

“These observations implied smoother cycling movement in WVF which might generate more power output due to better coordination in the lower limb function

“Addition of visual feedback improved both neuromuscular control and overall cycling performance”

Clinical Relevance
Could facilitate learning of more symmetrical muscle activation

Could potentially restore joint ROM and improve walking ability

PEDro Score
4/10
Evaluate the effect of EMG-BF treatment on upper extremity spasticity, hand function, and ability to perform ADL during the rehabilitation of patients with hemiplegia due to CVA.
Subjects
40 patients were enrolled out of the 80 who developed hemiplegia due to a CVA
17 did not meet inclusion criteria

2 refused to participate

9 were lost due to development of systemic problems

5 lost to development of social problems

3 lost to development of recurrent CVA

4 patients were missing data?

Methods
Participants were randomly assigned to 2 groups
One group was treated with EMG-BF and the other was not
Both groups participated in a hemiplegia rehabilitation program to relax spastic wrist flexors
Verbal encouragement
Conventional neurodevelopment method
Study group received 3 weeks of EMG-Bf treatment
5 times per week
20 minutes per session
On hemiplegic side wrist flexors while seated in comfortable position next to device in a quiet room with the wrist on a pillow at 90-degree of flexion
Electrodes were applied to wrist flexor motor points
Muscle activity was shown on a computer monitor as auditory and visual signals
Patient was instructed to try and maintain the muscle activity on the isoelectric line
Periodic verbal feedback was provided

Clinical assessment
Completed by an individual researcher unaware of group assignment before and after rehabilitation
Ashworth scale (AS) ; evaluates upper extremity spasticity

Brunnstrom’s stage (BS) of recovery for hemiplegic arm and hand ; evaluates upper extremity and hand motor function

Upper extremity function test (UEFT)

Wrist and hand position on the Fugl-Meyer scale (FMS)

Goniometric measurements of wrist extension

Surface EMG potentials

Barthel Index (BI) ; ability to perform ADLs

Statistics
Student t test

Chi squared test

Sign test

Wilcoxon’s signed-rank test

Mann-whitney U test

Look familiar? Non-parametric tests of differences

Findings

• Ashworth scale
• Brunnstrom’s stage
• Upper extremity function test
• Goniometric measurements of wrist extension
• Surface EMG potentials


Improvements posttreatment
Both groups had statisticially significant differences in the wrist and hand portion of the FMS and BI; with significantly greater improvements in the study group.

EMG-BF muscle activity measured with Student t test

Significant level was set at 0.025

There was a significant difference between posttreatment values in the study group (P < .001)

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.


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.

The Good and the Bad
Good
Both groups received conventional treatment and the only difference was that the experiment group received EMG-BF in addition to the normal treatment

No statistically significant differences between the study and control group in terms of patient age and sex; systemic disease, side, etiology, and duration of hemiplegia

Randomized and blinding of researcher who evaluated spasticity
Bad
The numbers don’t add up. The study says that 40 participants were divided into two groups of 20, when in fact there were 61 participants to begin with (30 in study group; 31 in control group).

1. eligibility criteria were specified – YES
2. Subjects were randomly allocated to groups (in a crossover study,
subjects were randomly allocated an order in which treatments were
received) - YES
3. Allocation was concealed - NO
4. The groups were similar at baseline regarding the most important
prognostic indicators – YES
5. There was blinding of all subjects – NO
6. There was blinding of all therapists who administered the therapy – NO
7. There was blinding of all assessors who measured at least one key
outcome - YES
8. Measures of at least one key outcome were obtained from more than
85% of the subjects initially allocated to groups – NO (66-64%)
9. All subjects for whom outcome measures were available received the
treatment or control condition as allocated or, where this was not the
case, data for at least one key outcome was analysed by “intention to
treat” – YES
10. The results of between-group statistical comparisons are reported for
at least one key outcome – YES
11. The study provides both point measures and measures of variability for
at least one key outcome - YES

6/10 (5/10, # 9, PEDRO site says NO)

PEDro
What do you think?
TMJ
Quadriceps
Re-education

Biofeedback-based Cognitive-Behavioral Treatment Compared With Occlusal Splint for Temporomandibular Disorder: A Randomized Controlled Trial
Subjects
58 patients with chronic TMD were randomly assigned to two groups
Methods
Biofeedback-Cognitive Behavioral Therapy (BFB-CBT) group
Occlusal Splint group
Each received 8 weekly sessions of treatment
Outcome Measures
Pain intensity and disability were defined as primary outcomes

Secondary outcomes included emotional functioning, pain coping, somatoform symptoms, treatment satisfaction, and adverse events.

Follow-up assessment took place 6 months after the treatment.
Results
Both treatments resulted in significant reductions in pain intensity and disability, with similar amounts of clinically meaningful improvement

Patients receiving BFB-CBT showed significantly larger improvements in pain coping skills

Satisfaction with treatment and ratings of improvement were higher for BFB-CBT

Effects were stable over 6 months, and tended to be larger in the BFB-CBT group for all outcomes.
Conclusion
BFB-CBT as well as Occlusal Splints were shown to be effective for chronic TMD patients

It is clinically relevant that pain and disability were reduced significantly with BFB-CBT, but we can’t adopt this treatment approach exactly because of the psychological treatment

This would be considered out of the scope of our practice, but it is important to be aware of the psychological involvement of this particular disorder.
The Relative Efficacy of Three Cognitive-Behavioral Treatment Approaches to Temporomandibular Disorders
Authors: Kiran D. Mishra, Robert J. Gatchel, Margaret A. Gardea
Subjects
94 patients with chronic TMD were assigned to one of four groups
Methods
Biofeedback treatment group

cognitive-behavioral skills training (CBST) treatment group

combined (combination of biofeedback/CBST) treatment group

No-treatment control group.


Pain scores were analyzed pretreatment and posttreatment to determine group and within-subjects treatment effects.
Outcome Measures
Results
In terms of a self-reported pain score, all three treatment groups had significantly decreased pain scores from pretreatment to posttreatment, while the no-treatment group did not

Moreover, patients in the biofeedback group were the most significantly improved compared to the no-treatment group

Finally, participants in the three treatment groups displayed significant improvement in mood states
Conclusion
This study shows that even biofeedback treatment alone can be effective for pain reduction in chronic TMD patients which would be clinically relevant for any PT that treats this type of patient.
Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders.
Authors: DC Turk, HS Zaki, TE Rudy
Design
Intraoral appliances (IAs) and biofeedback (BF) were examined separately and in combination; so two studies were conducted
First Study
Methods
Directly compared IA treatment, a combination of biofeedback and stress management (BF/SM), and a waiting list control group in a sample of 80 TMD patients
Results
IA treatment was more effective than the BF/SM treatment in reducing pain after treatment

At a 6-month follow-up the IA group significantly relapsed, especially in depression, whereas the BF/SM maintained improvements on both pain and depression and continued to improve
Second Study
Methods
The second study examined the combination of IA and BF/SM in a sample of 30 TMD patients.
Results
The combined treatment approach was more effective than either of the single treatments alone, particularly in pain reduction, at the 6-month follow-up
Conclusion
These results support the importance of using both dental and psychologic treatments to successfully treat TMD patients if treatment gains are to be maintained.
Long-Term Efficacy of Biobehavioral Treatment of Temporomandibular Disorders
Authors: Margaret A. Gardea, Robert J. Gatchel, and Kiran D. Mishra
Subjects
A total of 108 chronic TMD patients (seeking treatment for symptoms present at least 6 months)

men and women, between the ages of 18 and 65, with TMD and who were willing to participate

diagnosed as having TMD, using the RDC criteria

Exclusion Criteria
individuals with a significant physical condition such as cancer, low-back pain and fibromyalgia

people with six or more DSM-IV Axis I diagnoses

diagnosis of psychosis or active suicidal ideation

those who did not meet the RDC criteria
Methods
Randomly assigned to one of four treatment conditions
Biofeedback (n= 27)

Cognitive Behavioral Skills Training (CBST) (n=24)

Combined biofeedback and CBST (n=29)

No-treatment comparison (n=28)
Patients were evaluated in a standardized manner,
Research and Diagnostic Criteria (RDC) for TMD (Dworkin and LeResche, 1992)

Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID)
Subjects in each treatment group received 12 individual sessions that lasted approximately 1–2 hours each
For the first 4 weeks, sessions were conducted twice a week, with the last four sessions spread 1 week apart

Patients were then reevaluated upon completion of the standardized 12 sessions and 1 year after the completion of treatment.
Outcome measures
Outcome measures derived from the RDC were used to evaluate pain severity, disability, and physical functioning.
Pain
Disability
Limitations related to mandibular functioning
The Characteristic Pain Index (CPI)
Measures severity of pain
Ranges from 0 to 100, with 100 being the most intense pain
Calculated by taking the mean score of current pain, worst pain, and average pain scores (questions 7–9), and multiplying by 10
The Graded Chronic Pain Scale (GCPS)
Derived from the CPI score, as well as disability days and change in activities due to pain
Ranges from 0 (absence of TMD pain) to IV (high disability, severely limiting pain
Determined by a brief (12-item) checklist
Patients report whether or not an activity (e.g., chewing, talking, yawning) is limited due to their current jaw problem
Ranges from 0 (no limitations) to 12 (maximum limitations
Results
Characteristic Pain Index was statistically significant in the combined and biofeedback groups when compared to the no treatment group

Disability (graded chronic pain severity) was statistically significant in the combined group when compared to the no treatment group

Limitations in mandibular functioning were statistically significant when comparing the combined group to the no treatment group as well as when comparing the CBST group to the no treatment group.
Internal Validity
This study may have some threats to internal validity because it was lacking: concealed allocation, blind subjects, blind therapists, and blind assessors
External Validity
I think it may be hard to generalize the findings of this study because of the ‘combined’ treatment

As PT’s we probably won’t be able to assist with the cognitive behavioral skills training because that is out of our scope

But, I do think these results support the use of EMG biofeedback for chronic TMJ patients

The results were statistically significant for pain reduction when comparing the biofeedback group to the no treatment group; so I think this fact alone has clinical relevance
Clinical Relevance
In my opinion, this study has clinical relevance

EMG biofeedback machines are very common and pretty inexpensive. They are easy to use and allow the patient to receive information about their muscle activity

In addition, EMG biofeedback is very safe and really has no contraindications because the electrical current is not entered into the patient, and it is only a receiver

Therefore, there would really be no risks at all to giving this particular treatment a try with chronic TMJ patients

But, I definitely think we need to remember that modalities are not stand alone treatments, we’ll also need to incorporate exercise, habit changing, relaxation techniques, soft tissue assessment, etc. to really do the most good for our patients
PEDro
6/10

One point was given for each of the following: random allocation, baseline comparability, adequate follow-up, intention-to-treat analysis, between-group comparisons, and point estimates and variability

This study did not receive a point for each of the following: concealed allocation, blind subjects, blind therapists, and blind assessors
Questions?
Comments?
Authors: B Hemmen and HAM Seelen

Autors: Johanna Jonsdottir, Davide Cattaneo, Mauro Recalcati, Alberto Regola, Marco Rabuffetti, Maurizio Ferrarin and Anna Casiraghi

Authors: Sang-l Lin, Chao-Chen Lo, Pei-Yi Lin, Jia-Jin J. Chen

Authors: Meryem Doğan- Aslan, Gűldal Funda Nakipoğlu- Yűzer, Asuman Doğan, Ilkay Karabay, and Neşe Őzgirgin

Bibliography
The Effectiveness of Electromyographic Biofeedback Supplementation During Knee Rehabilitation
Authors: C. Silkman and J. Mckeon

Systematic Review

Looked at 4 studies

Total patients: N=152

Findings
Two studies demonstrated EMG BFB was effective (1 post menesectomy, 1 patello-femoral pain syndrome) compared to just an exercise program

Two studies showed no difference ( 2 patello-femoral pain syndrome) compared to just an exercise program

Electrical Stimulation Versus Electromyographic Biofeedback in the Recovery of Quadriceps Femoris Function Following Anterior Cruciate Ligament Surgery
Authors: Vanessa Draper & Lori Ballord

Subjects
N=30

All underwent an bone-tendon-bone patellar tendon autograph ACL reconstruction

Methods
Two Groups (E-Stim & EMG biofeedback)

Received familiarization with training and testing methods during a pre-operative therapy session

All received a home exercise program either incorporating E-Stim or EMG biofeedback

Participants wrote in journals to document their accurate home exercise program

Results
Subjects were tested using a Cybex II isokinetic dynamometer

EMG BFB group recovered 46.4% of their non-operative limb’s peak torque after 6 weeks

E-stim recovered 37.9% of their non-operative limb’s peak torque

There was no difference noted between groups in active knee extension range

The Efficacy of EMG Biofeedback Training on Quadraceps Muscle Strength in Patients After Arthroscopic Menisectomy
Authors: M. Kirnap, M. Calis, A. Turgut, M. Halici, M. Tuncel

Subjects
N= 40

All underwent arthroscopic menesectomys

Methods
Control group underwent a classic exercise program

Experimental group underwent the same classic exercise program plus five sessions of EMG biofeedback

Results
EMG BFB group showed a greater increase in VMO and VL EMG output (95 & 98%) of their operated leg compared to their non-operated leg after 6 weeks

Control group was at 43% and 58% compared to their non operated leg

The influence of electromyographic biofeedback therapy on knee extension following anterior cruciate ligament reconstruction: a random controlled trial
Authors: Franz Christanell, Christian Hoser, Reinhard Huber, Christian Fink, and Hannu Luomajoki

Subjects
N=16

12 Male, 4 Female

All Patients underwent endoscopic ACL reconstruction using patellar tendon autographs

All patients used the same surgeon from the University Clinic of Innsbruck in Austria

Methods
Both groups received the same basic therapy:

6 weeks of therapy
16 “Physiotherapy” sessions (40 min)

8 electro stimulation sessions (20 min)

8 manual lymphatic drainage sessions (30 min)

8 underwater hydrotherapy sessions (30 min)

The experimental group also received EMG biofeedback (EMG BFB) during their first week, and during each “Physiotherapy” session for the next 6 weeks

Measurements
Researchers tested participants pre-operatively and at weeks 1,2,4,6 post-op

Measured using:

High Heel Distance test (HHD)

Range of Motion (ROM)

Integrated EMG (iEMG) on the Vastus Medialis

Results
Week 1 post-op showed the greatest reduction in VMO strength for both groups (16.7% BFB, & 9.7% control)

Week 6 post-op VMO strength week 6 (BFB 124.9% ± 52%, Control 70.3% ± 45.8%)

Researchers also found a moderate correlation between EMG and HHD (-0.602, p<0.01)

PEDro
Eligibility criteria was specified: Yes
Subject allocation was random: No
Allocation was concealed: No
Groups were similar at baseline: Yes
Blinding of subjects: No
Blinding of therapists: No
Blinding of assessors: No
Adequate follow up: Yes
Intention to Treat Analysis: No
Between group statistical comparison reported: Yes
Provides both point measures and variability : Yes
Score:4/10

Are you still awake??
PEDro
5/10
Vote for PEDro!
PEDro
4/10
PEDro
5/10
Notch Filter
Authors: Meike C Shedden Mora, Daniel Weber, Andreas Neff, Winfried Rief
B Hemmen, H. S. (2007). Effects of movement imagery and electromyography-triggered feedback on arm-hand function in stroke patients in the subacute phase. Clinical Rehabilitation , 21, 587-594.

Ballord, L., & Draper,V. (1991) Electrical Stimulation Versus Electromyographic Biofeedback in theRecovery of Quadriceps Femoris Muscle FunctionFollowing Anterior Cruciate Ligament Surgery. Physical Therapy Journal,71:455-461

Christanell, F., et al. (November 6, 2012)The Influence of electromyographic biofeedback therapy on knee extensionfollowing anterior cruciate ligament reconstruction: a randomized controlledtrial. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology,4:41. Retrieved from HTTP://www.smartjournal.com/content/4/1/41

Gardea, M. A., Gatchel, R. J., & Mishra, K. D. (2001). Long-Term Efficacy of Biobehavioral Treatment of Temporomandibular Disorders. Journal Of Behavioral Medicine, 24(4), 341-359

Johanna Jonsdottir, D. C. (2010). Task-Oriented Biofeedback to Improve Gait in Individuals with Chronic Stroke: Motor Learning Approach. Neurorehabilitation and Neural Repair , 478-485.

Kirnap, M., et al. (October28, 2005) The Efficacy of EMG Biofeedback Training on Quadriceps MuscleStrength in Patients After Arthroscopic Menisectomy. The New Zeland Medical Journal, 118:1224

Meike C Shedden Mora, D. W. (2013). Biofeedback-based Cognative-Behavioral Treatment Compared with Occlusal Splint for Temporomandibular Disorder: A Randomized Controlled Trial. The Clinical Journal of Pain , 29 (12)

Meryem Dogan-Aslan, G. F.-Y. (2012). The Effect of Electromyographic Biofeedback Treatment in Improving Upper Extremity Functioning of Patients with Hemiplegic Stroke. Journal of Stroke and Cerebrovascular Disease , 21 (3), 187-192.

Mishra, K. D., Gatchel, R. J., & Gardea, M. A. (2000). The Relative Efficacy of Three Cognitive-Behavioral Treatment Approaches to Temporomandibular Disorders. Journal Of Behavioral Medicine, 23(3), 293-309.

Sang-l Lin, C.-C. L.-Y.-J. (2012). Biomechanical assessments of the effect of visual feedback on cycling for patients with stroke. Journal of Electromyogrophy and Kinesiology , 582-588.

Silkman, C., & Mckeon, J. (2010) Theeffectiveness of Electromyographic Biofeedback Supplementation Durring Knee RehabilitationAfter Injury. Journal of Sport Rehabilitation, 19:343-351

Turk, Zaki, & Rudy. (1993). Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. Journal of Prosthetic Dentistry, 70(2), 158-64.

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