EMG Biofeedback Training for a Mentally Retarded

Individual with Cerebral Palsy

HIDEO ASATO, PhD,

DENNIS G. TWIGGS, PhD,
and SHELLEY ELLISON, BS

Electromyographic biofeedback training was used to facilitate finger and wrist

extension movements in a mentally retarded individual with spastic hemiplegia.
The client was a 29-year-old woman with profound mental retardation and
cerebral palsy as a result of postnatal meningitis. During treatment, the client
demonstrated a short attention span, lack of motivation, low frustration toler-
ance, and increased spasticity in her left hand. The client was able to hyperex-
tend her fingers following finger extension training, although goniometric mea-
surements showed a marked degree of wrist flexion and wrist ulnar deviation.
Therefore, training was implemented to develop wrist extension movements.
Biofeedback therapy resulted in a substantial increase in active wrist extension
and a marked reduction in wrist ulnar deviation.

Key Words: Biofeedback, Mental retardation, Cerebral palsy, Electromyography.

Uses of muscle biofeedback in the treatment of
individuals with various neurological disorders are
just beginning to be explored.1 The major thrust of
neuromuscular reeducation has emphasized inhibi­
tion of spasticity, recruitment of motor unit activity,
and muscle relaxation.2 For instance, EMG biofeed­
back has been used to develop inhibitory control of
spastic gastrocnemius muscles,3 recruit tibialis ante­
rior muscle activity in paralytic foot-drop,4,5 and relax
sternocleidomastoid muscle in spasmodic torticol­
lis. 6,7 Electromyographic biofeedback training has
also been used to inhibit abnormal muscle synergy
and restore normal synergy.8 This article reports the
results of a study to determine the effectiveness of
electromyographic biofeedback in facilitating finger
and wrist extension movements in a mentally retarded
individual with spasticity of wrist flexor muscles.
METHOD
The client was a 29-year-old woman who func­
tioned in the profound range of mental retardation.
Her mental retardation and cerebral palsy (spastic
left hemiparesis) was the result of postnatal menin­
Dr. Asato is Clinical Psychologist, Department of Psychology, San
Antonio State Hospital/School, Box 23310, Highland Hills Station,
San Antonio, TX 78223 (USA).
Dr. Twiggs is Director, Rehabilitation Therapies, San Antonio
State Hospital/School.
Ms. Ellison is Director of Physical Therapy, Rehabilitation Ther-
apies, San Antonio State Hospital/School.
This article was submitted June 11, 1980, and accepted March 22,
1981.
gitis. Her mental age was 2.7 years with an IQ of 13
and she functioned at Level III on the Adaptive
Behavior Scale. The client's expressive communica­
tion skills consisted of two- and three-word utterances
(noun-verb combinations). Language receptive skills
included performance of appropriate action following
a simple verbal request, responding correctly and
nonverbally to questions concerning physical condi­
tion (eg, "Are you tired?"), and demonstrating an
awareness of positional concepts (eg, "up-down," "in-
out," "under-over").
The physical therapy assessment results indicated
the left upper extremity position was characterized by
shoulder adduction and internal rotation, elbow hy-
perextension, forearm pronation, wrist and finger
flexion, and wrist ulnar deviation. Goniometric mea­
surements indicated 84 degrees wrist flexion, 66 de­
grees of wrist ulnar deviation, and full finger flexion.
The thumb was "indwelling." Weakness and spastic­
ity were present in the left upper extremity: weakness
was characterized by muscular atrophy in the hand
and forearm, and spasticity was indicated by an es­
sentially nonfunctional clubbed hand. Calluses were
also noted over the proximal interphalangeal joints
of her left hand. These calluses were self-inflicted
wounds we thought occurred because of the client's
frustration and inability to use the affected limb. The
only functional use of the left hand was giving occa­
sional assistance to the right extremity.
The client received daily physical therapy at this
institution for 35 weeks before biofeedback training.
Goals of treatment were 1) to strengthen and increase

Volume 61 / Number 10, October 1981 1447

functional ability of left upper and left lower extrem­
ities and 2) to improve gait posture. The various
therapeutic techniques implemented to initiate func­
tional nonsynergistic movements included 1) stimu­
lation of cutaneous receptors by light stroking and
brushing, 2) encouragement of spontaneous explora­
tory movements of a relaxed extremity in relation to
various objects situated around the individual, 3)
passive exercise, and 4) active assistive exercise.
As a result of the client's short attention span, lack
of motivation, and low frustration tolerance during
physical therapy, spasticity in her left hand increased
during treatment, and no functional improvement
was observed after 35 weeks of therapy. Biofeedback
therapy was initiated to circumvent the motivational
problems encountered in physical therapy and to
provide a method of restoring upper extremity func­
tion. Although the client was profoundly mentally
retarded, she possessed a modicum of cognitive abil­
ities that made it possible for biofeedback training to
be implemented in conjunction with regular physical
therapy programing.
Treatment of motor system dysfunction is guided
by the principle that distal motor development follows
proximal motor development.9 Application of the
proximodistal principle for an individual exhibiting
weakness and spasticity in the hand means initiating
wrist extension training before finger extension train­
ing. We found that an alternative method of treatment
was indicated in our case, however, because of several
factors: 1) a significant amount (66°) of wrist ulnar
deviation, 2) a profound level of mental retardation,
and 3) a noticeable increase in motivational level of
the client after finger extension during the initial
session of biofeedback training.
Biofeedback Training: Finger Extension
A 30-minute baseline session was conducted to
determine whether the client could exhibit finger or
wrist extensor movements without the occurrence of
abnormal, synergistic movements. The following se­
quence of synergistic movements typically preceded
finger extension: shoulder abduction, elbow flexion,
shoulder external rotation, forearm supination, and
elbow hyperextension. To facilitate extensor move­
ments, a pillow was placed on the client's lap with
her hands resting on top of the pillow and with open
palms facing down. At the beginning of the baseline
session, the client was given verbal instructions for
performing extensor movements ("Raise your hand")
and was also provided with a model of the appropriate
response.
After this baseline session, training sessions were
conducted to determine the efficacy of biofeedback
therapy in facilitating hand extensor movements.
There were 13 training sessions with an average of 2
sessions a week. Each session lasted about 30 minutes.
1448
During the initial training session, the function of
the biofeedback device was explained to the client by
stating that music would be turned on if she displayed
extension movements of her left hand. Verbal instruc­
tions were accompanied by passive extension of the
client's wrist and fingers in order to 1) demonstrate
the biofeedback principle and 2) serve as a procedure
for shaping the desired response. The therapist also
provided a model of the appropriate response by
demonstrating wrist-finger extension. The procedure
of passively extending the client's wrist and fingers
was not repeated after the initial training session
because she demonstrated an understanding of the
feedback principle: she was able to exhibit an exten­
sion response (of her fingers) after the verbal instruc­
tion ("Turn the music on!") and modeling cues were
given. A motor response that occurred immediately
after passive extension of the client's hand was not
defined as an extension response initiated by the
client. Although the client's interest and motivation
were quite noticeable, she was not able to demonstrate
any wrist extension movements during the initial
training session. The client's inability to demonstrate
any wrist extension responses may have been due to
a marked degree of wrist ulnar deviation. Therefore,
the remaining therapy sessions incorporated finger,
and not wrist, extension training.
In the remaining sessions (2-13) for finger extensor
training, the client was given a verbal cue ("Turn the
music on!") and a modeling cue (therapist performing
wrist-finger extensor response) as the method of ini­
tiating the appropriate response. There was a total of
15 trials for each training session. If finger extension
occurred without any cues (verbal or modeling), it
was defined as a "spontaneous finger extensor re­
sponse."
Biofeedback Apparatus
Surface silver/silver chloride pregelled electrodes*
were placed over the extensor digitorum communis
muscle. (Skin-electrode impedance was measured 10
minutes after electrode application and found to be
about 10k Ω.) Muscle activity was monitored by a
Model S75-01 Bioamplifier† operated in the EMG
mode. Myoelectric potentials were detected, ampli­
fied, filtered (90 to 1,000 Hz), rectified, and integrated.
A threshold feedback program was devised by hav­
ing integrated muscle signals fed into a potentiometer.
The potentiometer was used to detect the presence of
signals above a predetermined voltage. Whenever a
signal was above threshold, the potentiometer acti­
vated a timer that determined the duration that an
AC switch (optically isolated between system and
* Vermont Medical Inc, Rockingham Rd, Bellows Falls, VT
05101.
† Coulbourn Instruments, Box 194, Laramie, WY 82070.
PHYSICAL THERAPY
Figure. Development of finger and wrist extensor responses as a function of neuromuscular reeducation in a
hemiplegic mentally retarded individual. I = finger extension; J = finger extension—verbal/modeling
cues; A = wrist and finger extension; and = wrist flexion and finger extension.)

load) supplied an external device (eg, FM radio) with
110 V alternating current (VAC). Thus, a training
program for coordinating EMG activity and feedback
(music) was implemented by having an AC control
provide an FM radio with 110 VAC. A timer deter-
mined the duration of feedback whenever muscle
activity was above threshold. For example, if the
feedback timer was set for 10 seconds, any EMG
potentials above the preset threshold level (on the
potentiometer) for 1,000 msec activated the timer and
led to presentation of feedback for 10 seconds. When-
ever muscle activity was above threshold during the
feedback period, the timer automatically reset itself
and feedback continued for 10 more seconds. If EMG
activity remained above threshold level, the feedback
recycled continuously for 10 second intervals.
Results: Finger Extension Training
A baseline session was conducted to determine the
frequency of wrist or finger extensor movements ini-
tiated by the client without the occurrence of syner-
gistic movements. No wrist or finger extensor re-
sponses were observed during the baseline session.
At the beginning of biofeedback training, threshold
for EMG activity was set at approximately 30 µV.
sec so that minimal extensor movements could initiate
the feedback process. As training progressed and as
finger extension improved sufficiently, the threshold
for feedback was increased (about 5 to 10 µV.sec a
session) so that a stronger extension response was
required to initiate feedback. If a training session
began where the level of the extensor response was
below the threshold level set for the previous session,
the threshold for EMG activity on the potentiometer
was lowered to a point about 5 to 10 µV.sec above
the resting EMG. This procedure increased the prob-
ability of a weaker extensor response initiating feed-
back (FM music) and thus strengthened the response
itself. However, during most of the training sessions,
threshold for EMG activity was slowly increased as

Volume 61 / Number 10, October 1981 1449

the client showed progressively greater improvement
in extensor motor responses (Figure).
By the end of the sixth session, the client was able
to hyperextend (15°) the metacarpophalangeal joints
of her fingers on cue for all 15 trials without initiating
any abnormal synergistic movements (Figure). Prior
to therapy, the resting position of her metacarpo­
phalangeal joints was 95 degrees. The thumb re­
mained indwelling throughout therapy. After 10 ses­
sions, the client was able to perform this extensor
response without cues on 90 percent of the trials.
At the termination of finger extension training,
goniometric measurements showed that hyperexten-
sion of the fingers was accompanied by 52 degrees of
wrist flexion and 47 degrees of wrist ulnar deviation.
This indicated a net increase in the client's ability to
extend her wrist 32 degrees actively.
Wrist Extension Training
At the end of finger extension training, extensor
movements were accompanied by a marked degree of
wrist flexion. To alleviate this condition, training was
implemented to develop wrist extensor movements.
The schedule was similar to the one implemented for
finger extension training (two sessions a week). The
client's hands were placed on top of a pillow with
open palms facing down. Verbal instructions were
given to the client ("Turn the music on!") along with
passive extension of the wrist to demonstrate the
appropriate response. A therapist also modeled the
appropriate response for the client.
During the initial training session, the client ex­
hibited a great deal of confusion as a result of the
change in the desired response (ie, wrist extension as
opposed to finger extension). In order to maintain the
biofeedback setting as a pleasant and therapeutic
environment, the remaining sessions were conducted
without the new response demand (wrist extension)
placed on the client. The only instruction given to the
client was "Turn the music on!" Whenever an exten­
sor response occurred with wrist flexion, the therapist
brought the wrist slowly and progressively into exten­
sion. This training procedure to reduce wrist flexion
was conducted for eight weeks (16 sessions). Electrode
placement for recording wrist extensor movements
was the same as the placement used for recording
finger extensor responses.
Results: Wrist Extension Training
One month after the termination of wrist extension
training, a probe (follow-up session) was conducted
to determine the efficacy of training. The client was
able to initiate extensor movements on all 15 probe
trials without any cues (verbal or modeling). In 80
percent of the probe trials (see Probe in Figure),
1450
finger hyperextension was accompanied by wrist ex
tension (0 to 10°). On the remaining probe trials
finger hyperextension was accompanied by wrist flex
ion (52°). Finger extension was observed in all 15
trials: a 10 percent improvement in the response after
wrist extension training. At the end of wrist extension
training, goniometric measurements showed that fin-
ger hyperextension was accompanied by 10 degree
of wrist extension and 45 degrees of wrist ulnar
deviation. (Before biofeedback training, goniometric
measurements indicated 84 degrees of wrist flexion
and 66 degrees of wrist ulnar deviation.) Biofeedback
therapy resulted in a net increase of 94 degrees of
active wrist extension and a reduction of 21 degrees
of wrist ulnar deviation.
During early training sessions the client occasion­
ally complained of soreness in her arm, which appar­
ently reduced her motivation to respond. In later
sessions, however, no complaints of soreness were
made during biofeedback training. A marked soften­
ing of the calluses on her proximal interphalangeal
joints was noted and she began to initiate attempts to
grasp objects (parallel bars, doors, toys) with her left
hand.
One year following biofeedback training, several
members of other disciplines have reported that the
client has attempted to make extensor hand move­
ments in various settings outside biofeedback therapy.
In the dormitory, staff members commented that the
client frequently demonstrated finger and wrist exten­
sor responses and appeared quite pleased that she
could perform this movement. This same observation
was also made by staff in the client's speech therapy
class. In physical therapy, the technician reported that
the client started placing her extended left hand over
the parallel bar (when she walked between them) and
over textured surfaces (when she made horizontal
movements with the hand). In dance therapy, she
started clapping with her left hand to music, held
hands with other patients to form a circle, and used
her open left hand to pat her thigh. These behaviors
were observed frequently by the dance therapist since
the initiation of biofeedback therapy.
COMMENTS
Muscle reeducation studies generally use feedback
in both auditory and visual modalities. There are
attentional deficits in mentally retarded individuals,
however, that influence the choice of modality. In a
study designed to assess the nature of attentional
problems that impair performance, Krupski reported
that retarded participants exhibited a greater degree
of off-task glancing than nonretarded participants in
a visual reaction-time task.10 On the other hand,
Harrison and associates found that an auditory cue
(music) facilitated manual dexterity in severely and
PHYSICAL THERAPY
profoundly retarded individuals.11 These findings in­
dicate that feedback presentation in the auditory
mode may be an initial point of investigation in
training the mentally retarded population to process
information.
In our study, auditory feedback (FM music) was
effective in facilitating the appropriate motor re­
sponses. The effectiveness of biofeedback therapy
also seemed to be related to the observation that the
client was in a setting where she had control of the
contingencies: music could be turned on by the client
whenever a finger and wrist extensor response (EMG
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3. Amato A, Hermsmeyer CA, Kleinman KM: Use of electromy-
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4. Basmajian JV, Kukulka CG, Narayan MG, et al: Biofeedback
treatment of foot-drop after stroke compared with standard
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Volume 61 / Number 10, October 1981
activity) exceeded the preset threshold level. Severely
and profoundly retarded individuals typically en­
counter situations where others take care of their
needs and thus develop a history best described as
"learned helplessness."12 In contrast, biofeedback
therapy provides a setting in which the contingencies
are determined by the individual. The rapid devel­
opment of extension movements and the observations
that improved motor function appeared outside the
therapy setting indicate the possibilities of EMG bio­
feedback in neuromuscular reeducation for mentally
retarded individuals.
7. Korein J, Brudny J, Grynbaum BB, et al: Sensory feedback
therapy of spasmodic torticollis and dystonia: Results in
treatment of 55 patients. Adv Neurol 14:375-402, 1976
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9. Ayres AJ: Ontogenetic principles in the development of arm
and hand functions. AJOT 8:95-99, 1954
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83, 1977
11. Harrison W, Lecrone H, Temerlin MK, et al: The effect of
music and exercise upon the self-help skills of nonverbal
retardates. Am J Ment Defic 71:279-282, 1966
12. Seligman MEP: Helplessness: On Depression, Development,
and Death. San Francisco, CA, W. H. Freeman & Co, Pub-
lishers, 1975, pp 181-188
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