Rehabilitation of Upper Extremity Nerve Injuries Using Surface EMG Biofeedback: Protocols for Clinical Application

Agnes Sturma, Laura A Hruby, Cosima Prahm, Johannes A Mayer, Oskar C Aszmann, Agnes Sturma, Laura A Hruby, Cosima Prahm, Johannes A Mayer, Oskar C Aszmann

Abstract

Motor recovery following nerve transfer surgery depends on the successful re-innervation of the new target muscle by regenerating axons. Cortical plasticity and motor relearning also play a major role during functional recovery. Successful neuromuscular rehabilitation requires detailed afferent feedback. Surface electromyographic (sEMG) biofeedback has been widely used in the rehabilitation of stroke, however, has not been described for the rehabilitation of peripheral nerve injuries. The aim of this paper was to present structured rehabilitation protocols in two different patient groups with upper extremity nerve injuries using sEMG biofeedback. The principles of sEMG biofeedback were explained and its application in a rehabilitation setting was described. Patient group 1 included nerve injury patients who received nerve transfers to restore biological upper limb function (n = 5) while group 2 comprised patients where biological reconstruction was deemed impossible and hand function was restored by prosthetic hand replacement, a concept today known as bionic reconstruction (n = 6). The rehabilitation protocol for group 1 included guided sEMG training to facilitate initial movements, to increase awareness of the new target muscle, and later, to facilitate separation of muscular activities. In patient group 2 sEMG biofeedback helped identify EMG activity in biologically "functionless" limbs and improved separation of EMG signals upon training. Later, these sEMG signals translated into prosthetic function. Feasibility of the rehabilitation protocols for the two different patient populations was illustrated. Functional outcome measures were assessed with standardized upper extremity outcome measures [British Medical Research Council (BMRC) scale for group 1 and Action Research Arm Test (ARAT) for group 2] showing significant improvements in motor function after sEMG training. Before actual movements were possible, sEMG biofeedback could be used. Patients reported that this visualization of muscle activity helped them to stay motivated during rehabilitation and facilitated their understanding of the re-innervation process. sEMG biofeedback may help in the cognitively demanding process of establishing new motor patterns. After standard nerve transfers individually tailored sEMG biofeedback can facilitate early sensorimotor re-education by providing visual cues at a stage when muscle activation cannot be detected otherwise.

Keywords: nerve reconstruction; nerve transfer; neuro-rehabilitation; prosthetic rehabilitation; surface electromyography; upper extremity rehabilitation.

Figures

FIGURE 1
FIGURE 1
Training with the MyoBoy (Ottobock, Duderstadt, Germany) with one dry electrode placed on the extensor compartment of the forearm. The EMG signal’s amplitude is reflected by the LED dots. This set-up may be used for home training.
FIGURE 2
FIGURE 2
Surface EMG biofeedback set-up with the TeleMyo system (Noraxon, United States) and screenshot of the TeleMyo-Software simultaneously recording two EMG signals, represented by color-coded graphs.
FIGURE 3
FIGURE 3
Rehabilitation process of both patient groups.
FIGURE 4
FIGURE 4
(A–D) sEMG-guided rehabilitation for patients with biologic reconstruction of upper extremity function. The scheme illustrates the rehabilitation process following an Oberlin’s ulnar nerve transfer.
FIGURE 5
FIGURE 5
(A–D) sEMG-guided rehabilitation for patients with bionic hand reconstruction.

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