There were 14 chapters in the first edition of this book; there are 17 chapters in this second edition. The second edition retains 13 original chapters, the SEMG atlas and appendices.
Preface
Regardless of how SEMG is used, a solid foundation in SEMG principles is necessary for effectiveness. Key organizations in this field are the Association for Applied Psychophysiology and Biofeedback (AAPB) (the Surface EMG Society of North America is now the Surface EMG division of the AAPB), the Biofeedback Foundation of Europe, and the International Society for Electrophysiological Kinesiology (ISEK) (formerly the International Society for Electromyography and Kinesiology ).
ACKNOWLEDGMENTS
The term client is used in the chapter "Somatics and Surface Electromyography" because the participant in the somatic world is called the client and the practitioner is called an educator or practitioner. For example, SEMG research has appeared in more than 42 journals worldwide in the past 10 years.
Additional information is available in the companion book Clinical Applications in Surface Electromyography: Chronic Musculoskeletal Pain. I strongly recommend that readers study this highly scientific but pragmatic review of what we know about the use of SEMG in the treatment of a variety of conditions.
Preface to the First Edition
As with all manuscripts, literally hundreds of people helped bring this book to print. Will Taylor, Stu Donaldson, Jonathan Holtz, and Glenn Kasman helped create the boundaries and channels through which this introductory volume on SEMG flowed, but it was Glenn Kasman's dedication to working on this book that set it in motion.
Contributing Authors
T HE B ASICS OF S URFACE E LECTROMYOGRAPHY
THE HISTORY OF
SURFACE ELECTROMYOGRAPHY
Introduction
They concluded that almost all of the dysfunctional patterns in the upper back involve hyperactivity of the upper trapezius. Additionally, an excellent summary of the use of SEMG in the occupational setting can be found in a book by Soderberg.39.
THE ADVANTAGES AND DISADVANTAGES OF SURFACE ELECTROMYOGRAPHY
Taylor thus saw the hyperactivity of the upper trapezius as facilitated by the inhibition of the lower trapezius. Physiological action currents in the phrenic nerve: an application of the thermionic vacuum tube to nerve physiology.
BASIC OVERVIEW OF THE NEUROMUSCULAR SYSTEM
Anatomy and Physiology
The lower motor neuron associated with the motor unit lies in the ventral horn of the spinal cord. Part of the cortical flow goes directly to the lower motor neuron via the pyramidal tracts.
MUSCLE FIBERS AND HOW THEY WORK
The globular heads of the myosin thus function as cross-bridges for the actin chains. Figure 2–2 The composition of muscle cells, muscle fascicles, muscle fibers, myofibril, myofilaments, sarcomeres, thick and thin filaments.
SENSORY MOTOR INTEGRATION
Essentially, the inhibitory influence of the Golgi tendon organ protects the muscle from tearing its attachments. The output of the Golgi tendon organ terminates in the lower centers of the brain (i.e. the basal ganglia).
NERVOUS SYSTEM CONTROL
One of the important aspects of this sensory system is that we are aware of it. The sensory network of the muscles provides a wealth of information to the central nervous system regarding muscle function.
The Spinal Reflexes
Other aspects of cortical information are connected to the basal ganglia to capture the (acquired) reflexes needed to assist in this movement and to integrate other sensory organs, such as the eyes, into the movement. In addition, it has been demonstrated that when tonic neck reflexes are reintegrated, forearm firing decreases and conduction velocity in the carpal tunnel improves. it likely caused a slight flexion or extension of the upper extremity as the person turned their head one way or the other.
The Subcortex
Both the basal ganglia and the cerebellum act on the cerebral cortex via the relay nucleus of the thalamus.
The Cortex
The gamma motor system, whose origins lie mainly in the basal ganglia, carries out the 'old knowledge'. It regulates the resting length of the stretch receptors, through which our species-specific postures and behaviors are transmitted via con-. For the system as a whole to survive successfully, all the different parts are connected through feedback and feedforward loops that must be integrated with any given movement.
THE MOTOR UNIT
In other words, the central nervous system rotates the motor units that fire within a given muscle group. George Whatmore17 called this "solidification". In layman's terms it is referred to as "being tense".
FACTORS THAT AFFECT MUSCLE TENSION OR FORCE
Conversely, if the muscle fibers were constantly firing to counteract this force, they would soon become exhausted. This is where the smallest muscle fibers and motor units are recruited first, and larger muscle fibers and motor units come into play as the synaptic drive continues to increase.
Fatigue
In this way, the postural load on a muscle is transferred from one motor unit to another in a smooth and continuous manner. Furthermore, the recruitment strategy of the motor units can move from an asynchronous pattern to a synchronous pattern.
MOTOR UNIT RECRUITMENT PATTERNS
At normal resting length, the amount of tension produced by the muscle contraction (curve 3) is greatest. However, the total tension of the muscle increases with the elastic properties of the muscle when it is stretched (curve 2).
Length–Tension Relationships
In the case of concentric contractions, the amount of tension generated is moderated by the speed of the contraction. However, in the case of eccentric contractions, the amount of force or tension generated by the muscle actually increases as the speed of the eccentric contraction increases.
CHAPTER QUESTIONS
What percentage of motor neurons that leave the motor strip stop in the lower brain before going down to the lower motor neuron. In SEMG, which of the following might be expected to show the greatest recruitment pattern.
INTRODUCTION
THE SOURCE OF THE
ELECTROMYOGRAPHIC SIGNAL
Instrumentation
Figure 3–2 Components affecting the EMG signal source as it makes its way to the differential amplifiers. Additionally, if there is fat tissue between the muscle and the recording electrodes, it will absorb more of the signal.
IMPEDANCE
When the impedance at the electrode skin interface is too high or too unbalanced, the common mode rejection of the SEMG amplifier is lost. For this wonderful voltmeter to work, it is important that the skin resistance (Is) is less than the input impedance of the preamp (Ii).
DIFFERENTIAL AMPLIFICATION AND COMMON MODE REJECTION
As a result of rejecting the common mode, the thunder common to both microphones is subtracted from the signal, leaving only the birdsongs that are transmitted to the loudness meter. In contrast, the energy common to both recording electrodes—the common mode—is eliminated by this process.
FILTERING THE
The top line of the graph would represent the amount of force exerted over time. During muscle fatigue, there may be a downward shift in the form of the power filter (left side) and a 20-1000 Hz filter (right side).
SPECTRAL ANALYSIS, FATIGUE, AND BAND PASS FILTERS
However, if one were to use a band-pass filter of 100 to 200 Hz, only some of the muscle's energy would be observed. The median frequency of the spectrum is 92.2 Hz for the left aspect and 92.7 Hz for the right aspect.
TYPES OF SURFACE ELECTROMYOGRAPHY VISUAL DISPLAYS
Two spectral analyzes are noted: one for the right aspect and one for the left aspect of the muscle. Clearly, it is important to know the filter characteristics of the SEMG instrument so that clinicians can correctly interpret the signals.
The Raw Surface
In fatigued muscles, the shape of the frequency spectrum changes such that there is a reduction of the higher frequencies and an increase of the lower frequencies. A 1.7 second sample is taken from the middle of the contraction (marked by the vertical lines) and submitted for analysis.
Electromyography Display
The advantage of the raw SEMG trace is that it contains all the information of the SEMG signal. However, after cessation of movement, the SEMG activity level does not return to the resting baseline level.
The Processed Signal
For example, instead of showing each point in the corrected signal for the patient to interpret the signal. By plotting the average of every 6 data points, the variability of the SEMG is reduced by a factor of 6.
QUANTIFICATION OF THE SURFACE ELECTROMYOGRAPHIC SIGNAL
Visually, the smoothing process is represented by taking the bumps out of the signal - by reducing its variability. Figure 3-15 shows the corrected tracking with very little smoothing (every 6 points are averaged and then plotted).
COMPARISON OF QUANTIFIED SURFACE ELECTROMYOGRAPHY VALUES
ACROSS INSTRUMENTS
Such a signal generator has been described as a "synthetic muscle." This output was sent to the amplifiers of the special SEMG instruments. A mathematical ratio comparing all the SEMG instruments to the J&J M-501 SEMG amplifier was then calculated.
COMPARISON OF QUANTIFIED SURFACE ELECTROMYOGRAPHY VALUES ACROSS
The middle 2 seconds of a 6-second contraction are recorded and then averaged over three trials of MVIC. These values can then be used to calculate a percentage of MVIC for each muscle to compare the work done by the lower trapezius with that of the upper trapezius.
AMPLITUDE PROBABILITY DISTRIBUTION FUNCTION
The probability amplitude modulation curves provide the clinician with the opportunity to examine the variability of the SEMG signal. Clinically, amplitude-probability distribution function curves also allow examining the distribution of the SEMG signals for the occurrence of alternating rest during a work period.
AUDITORY DISPLAYS
Another major source of noise is 60-cycle energy: the kind of energy we use to power lights, offices and the computers used to monitor the SEMG. Clinicians may also want to eliminate all possible sources of 60-cycle noise in the recording environment.
ISSUES REGARDING NOISE AND ARTIFACT
Note how it is difficult to discern the motion artifact in the LSer trace of the processed EMG recording. Figure 3–20 (A) Raw SEMG trace contaminated with 60-Hz noise. B) Spectral analysis of the signal showing harmonics of 60-Hz noise.
HOW TO CHECK
A very clear example of cross talk is seen in frontal SEMG recordings when the patient. Cross-talk occurs when the energy of the masseter and temporalis muscles that are recruited during a contraction is taken from the frontal sockets.
SPECIFICATIONS OF SURFACE
Here the signals from a local radio station are picked up by the antenna effect of the electrode wires and fed to the amplifiers. If RF noise is suspected, it is necessary to move the SEMG instrument to another room or to the other side of the building.
ELECTROMYOGRAPHIC INSTRUMENTS
Computer raw and processed computer screens allow the operator to view scrolls of time series of SEMG information. What usually happens during muscle fatigue is the mean frequency of SEMG power density.
ELECTRODE SELECTION
Electrodes and Site Selection Strategies
This substance amplifies the biological signal from the skin to the electrode and provides a cushion that absorbs the movement of the electrode (housing) on the skin's surface. In addition, the adhesion to the skin is lighter, which makes it possible to easily remove the electrode.
ELECTRODE LEADS AND CABLES
SITE PREPARATION
Skin temperature is another factor that can noticeably affect site impedance and thus SEMG recordings. As skin temperature increases, impedance decreases; such fluctuations can also alter SEMG recordings.
STRATEGIES FOR ELECTRODE PLACEMENT
The electrodes are most often placed directly above or slightly lateral to the belly of the muscle. Widely placed electrodes on the trapezius group enable the practitioner to see any activations of the neck and.
FACTORS THAT AFFECT INTERPRETATION
75 Within the healing arts, it is generally assumed that the treatment must naturally spring from the practitioner's diagnostic impression. With SEMG, the practitioner makes a functional or clinical diagnosis; rather than diagnosing tissue damage, the practitioner considers the central nervous system's use or misuse of muscle energy.
Anatomical and
George Whatmore, one of the pioneers of SEMG, called this misuse of muscle energy dysponesis, or the poor use of energy.1. As with formal diagnosis, a strong functional diagnosis requires the clinician to “correctly” interpret the information collected during the assessment, basing the SEMG treatment protocol on this interpretation.
Physiological Considerations
General Assessment Considerations
Consider another example - the placement of the electrodes over the belly of the sternocleidomastoid (SCM) during axial rotation of the head. Such considerations are not part of SEMG activity in the static phase of the assessment.
Adipose Tissue
The body fat percentage would then form the basis for scaling up the interpretation. Therefore, it is prudent to consider the presence and positioning of the patient's adipose tissue when interpreting the amplitudes associated with SEMG information.
Position, Posture, and Dynamic Movement
Potential adaptation of SEMG amplitudes due to stretch receptor adaptation related to the time required to perform multiple samples. Additionally, note the suprasegmental organization of the paraspinal muscles, with the neck muscles being active.
Volume Conduction
For example, recruitment of the biceps during elbow flexion changes when the hand is pronated instead of supinated (see Figure 17-33D). Recruitment of the infraspinatus during abduction differs when the arm is medially or laterally rotated (see Figure 17-24B).
Age and Gender
SURFACE ELECTROMYOGRAPHY AND CLINICAL SYNDROMES
Although the issues to be considered are as diverse as the patients themselves, it is useful to consider some of the following elements: trauma, vocation, medical history, type of pain description, pain-related movements, temporal aspects of pain, breathing difficulties, cognitive dysfunction, visual /balance dysfunctions, headaches, incontinence, paresthesia, weakness, medication, substance abuse, major life stressors, affect, coping mechanisms and impaired daily activities. A case example is provided for each syndrome to provide an illustration of each of the concepts presented.
Simple Postural Dysfunction
Emotional Dysfunction
Learned Guarding or Bracing
An example of acute reflexive inhibition may be seen in a patient with a recent history of trauma and physical examination findings of swelling, tenderness, and inability to tolerate vigorous manual muscle testing of the lower extremity. Surface EMG monitoring would show a discrete focal decrease in SEMG amplitude recorded from the quadriceps during a painful portion of the knee ROM arc.
Learned Inhibition/Weakness
The focal decrease in SEMG activity in this case would be a consequence of neurophysiological inhibition. Similar scenarios involving spasms and inhibition can result from the cumulative effects of subtle, repetitive trauma to a joint.
Direct Compensation for Joint Hypermobility or Hypomobility
Peripheral Weakness or Deconditioning
Acute, Reflexive Spasm/Inhibition
There is a deviation of the midline of the jaw during opening and closing, and a marked difference between the movements of the mandibular condyles to the left and right. The underlying problem, however, is not that the right SEMG masseter activity is greater than that of the left masseter, but rather that the left joint has less mobility than the right joint.
Chronic Faulty Motor Programs
This roll/glide ratio is required for normal jaw range of motion and is expected to be symmetrical across the left and right TMJs. In this case, SEMG activity shows greater recruitment of the right masseter muscle during the jaw opening/closing range of motion.
ASSESSMENT/TREATMENT LINK
As an example, assume that a patient with jaw pain on physical examination shows left temporomandibular joint (TMJ) hypomobility. The right mandibular condyle translates a greater distance along the articular surface of the zygomatic process, and the right masticator is activated to a greater degree to subject the greater range of motion than the right TMJ.
AN UPPER QUARTER EXAMPLE
- Postural Muscle Stretching
- Isolation of Phasic Muscles
- Postural Muscle Relaxation
- Postural/Phasic Muscle Balance
- Isolation of Phasic Muscles*
Electrodes are placed on both the right and left sides of the upper part. Taylor uses the approach advocated by Janda,33 and. Bilateral placement refers to independent monitoring of the right and left aspects of the upper trapezius using a narrow placement (see electr-
CONCLUSION
Stereotyped Movement Patterns
Comparison of spinal mobility and isometric trunk extensor strength with electromyographic spectral analysis in identifying low back pain. Correlations of myoelectric asymmetry detected in patients with low back pain using portable post-style surface electromyography.
STATIC ASSESSMENT
Static Assessment and Clinical Protocol
For example, in some obese or exceptionally lean individuals, these factors may negate the validity of the normative data.
NORMATIVE DATA
The hyperactive pattern at the C-4 paraspinal site observed by comparing the group norm also has a significant hypoactive pattern on the contralateral side, as demonstrated by within-patient analysis.
WITHIN-PATIENT ANALYSIS
When the same data are submitted to a within-patient analysis (Table 6–6), only a few sites show activation. All of the microvolt readings are very low and appear to be within the normal range due to Table 6–5 Group Normal Analysis of an Extremely Thin.
SENSITIVITY AND SPECIFICITY
For example, scanning of the low back muscles (L-3 and T-10) more clearly distinguished normal patients from patients with low back pain while standing. These results were later replicated by Kessler, Cram, and Traue9 in a well-controlled study with a well-defined group of low back pain patients matched for age and sex to controls.
RELIABILITY
STABILITY OF THE SIGNAL
As Callet has stated, "Know what is normal, then you can distinguish what is abnormal."16 The patient's SEMG information should be examined for its level of activation or inhibition, its degree of asymmetry, and the extent to which it is altered with postural change (see appendix 6-1).
INTERPRETATION OF STATIC FINDINGS
HEADACHE EXAMPLE
LOW-BACK PAIN EXAMPLE
Such reflex-based splinting patterns are suggested when the pain complaint is on the ipsilateral side of the activation. In this particular case, a mild asymmetry is noted on the ipsilateral side of the patient's pain.
A Step-by-Step Description of the Clinical Procedure
The practitioner should hold the sensors in place with light pressure and avoid pressing too firmly. Because scanning electrodes are not held in place with adhesive tape, the electrodes must be manually held still for a period of 6 to 20 seconds.
THE CLINICAL PROCEDURE ASSOCIATED WITH THE STATIC ASSESSMENT
To record specific muscle groups, place the scanning electrodes so that they run parallel to the muscle fibers of the muscle in question. Typically, this problem occurs when a doctor who is new to scanning stays on site for too long.
Potential Problems and Pitfalls of the Procedure
Listening to the raw SEMG for the muscle action potentials (rather than the sum of the 60-cycle noise) can increase the exerciser's confidence in the validity of a high EMG reading. When observed, one can easily note the correlation between the variability of the SEMG reading and the patient's respiratory cycle.
COMPARISON CONSIDERATIONS
Cram has noted that patients who wear dentures are more likely to brace with these muscles. In addition, shoes and lifts can introduce another level of variance in the SEMG values.
LOCATIONS OF SCAN SITES AND INTERPRETATION FOR EACH SITE
He has also observed problems with the frontalis and cervical muscles in patients who have difficulty with glasses (usually bifocals); this problem can come from frowning, squinting, or tilting your head too much to see the right area of the lens. It has been suggested that elevations in the left aspect may be seen in patients who are prone to cardiac problems.
Anterior Temporalis Placement
Masseter Placement
Low Frontalis Placement
The top scanning electrode should be located below the hairline, approximately at the vertical center of the neck. Many muscle layers are present in this area; the scanning electrodes collect data from the upper fibers of the trapezius, the splenius capitis, the splenius cervicis and the semispinalis cervicis.
Sternocleidomastoid (SCM) Placement
Unilateral activation of these muscles may result in rotation or lateral flexion of the head; with bilateral activation, head extension may occur. In patients with poor posture, where the head is held forward of its center of gravity, these muscles are needed to provide chronic muscle support for the 15-kilogram weight of the head.
Cervical Paraspinal Muscles (C-4) Placement
When performing a scan of this location, it is important to notice if the patient is trying to assist the practitioner by leaning their head slightly forward. The cervical muscles have been indicated in headaches localized in the occipital and frontal regions.
Upper Trapezius Placement
T-1 and T-2 Paraspinal Muscles Placement
T-6 Paraspinal Muscles Placement
L-3 Paraspinal Muscles Placement
Abdominal Muscles Placement
T-10 Paraspinal Muscles Placement
If this is true, the readings may be lower due to attenuation of signals from fat tissue. Asymmetry can be observed in patients with lower back pain, but this is very unusual.
High Frontalis Placement
They are usually underdeveloped due to disuse and may be covered with a thick layer of fat.
Lateral Neck/Scalene Placement
Capitis Site Placement
Anterior Deltoid*
Posterior Deltoid*
The scanning electrodes are placed over the belly of the muscle, approximately half the distance between the shoulder and the elbow. The electrodes are oriented in a vertical plane to track the fibers of the muscle.
Wrist Extensors*
Wrist Flexors*
Pectoralis Major*
Biceps*
Triceps*
Gluteus Maximus*
Vastus Medialis and Vastus Lateralis*
Rectus Femoris*
Hamstring*
Gastrocnemius*
Soleus Placement
Paraspinal Muscles
Tibialis Anterior Placement
Digastric/Suprahyoid Placement
Posterior Temporalis Placement
At a similar site, T-7, 4 patients had abnormal radiographs; of the 14 patients who had a SEMG scan at this location, only 2 (14%) were asymmetric. The muscle scan assessment of the static component of the neuromuscular system provides information on which of the following.
MUSCLES AND EMOTIONAL DISPLAY
THE FACIAL MUSCLES
Emotional Assessment and Clinical Protocol
THE TRUNK MUSCLES
Anatomists16,17 have extensively studied the facial muscles and found that these muscles have direct anatomical connections with the lower centers of the brain (i.e., the facial nerves of the pontine nucleus). The findings clearly showed that only the patients with low back pain demonstrated an emotional response (activation pattern) in the left erector spinae muscles, and only during stressors relevant to the patient's condition.
RELATIONSHIP OF EMOTIONAL AROUSAL TO MUSCLE ACTIVATION
Given this strong connection with the reptilian brain, they concluded that the facial muscles could be considered an autonomous organ. This study suggests that the concepts of stimulus specificity are found in the trapezius and arm muscle groups, with response stereotypy occurring in the broad frontal placement.
THE STRESS PROFILING PROTOCOL
Trapezius and masseter muscles showed the greatest consistency during mental arithmetic (0.69 to 0.87), with much lower correlations during the other tasks (0.23 to 0.39). Only the broad frontal placement showed consistently high test-retest correlations across all tasks (0.80 to 0.91).
RELIABILITY OF STRESS PROFILING
The physician must monitor the patient's mental arithmetic process to capture the timing of this event. Here, the practitioner performs a baseline SEMG reading (state A), introduces a stressor (state B), and concludes the assessment with a recovery phase, commonly called post-baseline recording (back to state A).
PATTERNS OF ACTIVATION AND RECOVERY
In such cases, the practitioner can observe the results in terms of the physiological response in the SEMG or ANS channels. If the task is too difficult, the practitioner may want to explore other potential stressors.
Baseline Levels
Other options include playing the patient an audio tape that presents a variety of environmentally stressful sounds (eg, phones ringing, cars honking, dogs barking, babies crying).25 Or, as Flor and colleagues18 did , the therapist can make the stressor relevant to the patient by asking the patient to describe the pain or the impact of the pain on his or her life. Once the practitioner has selected the muscle sites to be monitored and the appropriate stressor for the patient, the practitioner should follow some form of standardized single-subject protocol.
Level of Response to the Stressor
In this table, the average SEMG level of both muscles is within the range of the other muscle during the pre-baseline phase. Muscle B did not recover well in comparison; the mean for the recovery phase for muscle B is greater than the range of the second standard deviation for the prebaseline phase.
Recovery to Prebaseline Levels
Finally, muscle A recovered rapidly from the stressor, and the recovery mean for muscle A is within the range of the prebaseline values for muscle A. If the mean of one muscle falls outside the range of the other muscle, then the conclusion is strengthened and clini - call significant .
DYNAMIC EVALUATION OF THE NEUROMUSCULAR SYSTEM
Dynamic Assessment
THE “TONIC BASELINE” AMPLITUDE
RECOVERY OF BASELINE LEVELS FOLLOWING MOVEMENT
ASSESSMENT OF TRIGGER POINTS
ISSUES PERTAINING TO THE WORK PEAK Symmetry of Recruitment
RANGE OF MOTION
History The patient has a history of spontaneous localized pain associated with acute overload or chronic overload of the muscle. This restriction is relieved by releasing the tensioned band by inactivating the trigger point.
ISSUES PERTAINING TO TEMPORAL FACTORS Flexion/Extension
For example, the clinician might ask the patient to perform the movement so that it has symmetry in the ROM at the smaller end of the ROM; the practitioner would observe this movement to see if a separation of muscle function occurs or if the co-contraction continues. Taking into account the patient's comfort zone, the doctor should allow the patient to increase his or her range of motion in a symmetrical manner; the practitioner would then observe the point at which the excessive activation begins.
Cocontractions
In addition, during the last 45 degrees of flexion and hanging, a flexion-relaxation response of the erector spinae muscles should be observed. The abnormal recruitment pattern in Figure 8-7 shows the absence of the flexion-relaxation response during the hanging phase of trunk flexion.
Agonist/Antagonist/Synergy Issues
In the normal body, however, such synergy is rarely seen and would probably disturb the glenohumeral rhythm of the shoulder. The examination of movement and stabilization of the shoulder and arm as described here is greatly simplified.
THE ISSUE OF REST
Figure 8-10 shows a recruitment pattern where the upper trapezius dominates the lower trapezius during this movement. Figure 8-9 An abnormal relationship in which the lower trapezius is over-recruited relative to the upper trapezius during 90-degree abduction.
RELIABILITY OF DYNAMIC SURFACE ELECTROMYOGRAPHY ASSESSMENTS
Figure 8–12 Probability amplitude distribution for (A) left and (B) right upper trapezius during a typing task for a patient with chronic neck and headache pain, predominantly on the right side. Figure 8-13 Probability amplitude distribution for the left (A) and right (B) upper trapezius during 20 minutes of typing for a patient with left-sided carpal tunnel syndrome.
ASSESSMENT OF THE PELVIC FLOOR
After the 10-second hold ends, the SEMG level drops rapidly and returns to the low resting tone level. Myofascial pain syndrome of the head and neck: a critical review of the clinical characteristics of 164 patients.
AN OVERVIEW OF TREATMENT
Treatment Considerations
The idea for the movement originates in the frontal lobes, the prefrontal cortex sets the general plan for the movement, the motor cortex tunes the finer aspects of the movement, and the cerebellum integrates the movement with the other senses, sets the postural tone through its control of collateral gamma motor activity, and constitutes the last link in the actual execution of the movement. The task of the practitioner is to understand and tease out this puzzle, to determine which part of the system has gone awry, and to work on the aspects of the problem that can be fixed.
Generalization of Training
Movement is controlled by many aspects of our being; it flows down through the complex neural network described in Chapter 2. Segmental and suprasegmental reflex arcs from the muscle spindle, Golgi tendon organs, Ruffini endings and free nerve endings influence the descending information at the level of the spinal cord, increasing the output for the last common pathway: the lower motor neuron.
Relaxation
Disease in any aspect of this highly complex system alters this pattern of recruitment and subsequent movement.
Posture
The idea for the movement originates in the frontal lobes, the prefrontal cortex determines the general plan for the movement.
Movement
For this reason, physicians should encourage patients to demonstrate their SEMG skills during activities of daily living.
Relaxation Strategies
Progressive Relaxation Training
First, the patient is asked to move the joint attached to the muscle as he or she deliberately stretches the muscle to the point of perceiving tension. As the training progresses throughout the sessions, the practitioner encourages the patient to become more aware of tension at lower levels of activation.
Autogenic Therapy
This phrase is followed by an observation period of at least 30 seconds in which the patient observes what is happening. On subsequent visits, the practitioner adds more phrases to the patient's cues, making the training sessions longer and more in-depth.
Guided Imagery
Breath Work
If practitioners want to work on calming a particular organ system or part of the body, they must target their language to those body parts and organs in very specific ways. The pattern of rhythmic activation is related to breathing and the improper use of the accessory muscles.
Muscle Learning Therapy
Generalization of Relaxation Training
DYNAMIC RELAXATION STRATEGIES
For example, there are sit-to-stand exercises, sit-to-stand exercises with reverse counting; blind sit-stand training; typing; walk; sit–walk–sit; and standing-to-lying. An excellent description of this protocol, including a 12-session description, can be found in the article by Ettare and Ettare.20.
Recovery Training
At the end of several training visits, the sit, stand, walk, stand, sit protocol is transformed into the SEMG recordings shown in Figure 9-5. Ettare and Ettare's rich protocol includes several variations on the theme of using controlled relaxation to facilitate skill transfer.
The Feldenkrais Method
Ask the patient to roll the shoulders to the right while he or she turns the head to the left. Ask the patient to turn his shoulders in the direction of turning his head as he would normally do.
SURFACE ELECTROMYOGRAPHIC FEEDBACK AND NEUROMUSCULAR REEDUCATION
Also have the patient stop every few minutes and rest for about half a minute. Encourage the patient to find the natural rotation of the trunk associated with this knee push.
Surface Electromyographic- Guided Stretching
During tucking, a strong burst of activity should be observed, followed by a return to the previous resting tone. A 10-second recruitment followed by a 50-second rest, with five repetitions, is a good starting point and provides a foundation for a simple home program that can be followed between visits.
Correction of Simple Postural Dysfunctions
Audio feedback is extremely useful in this regard, as it allows the patient to hear the amplitude of muscle activity without looking at a screen. If an audio threshold is available, the clinician could systematically shape progressively lower levels of SEMG activity by gradually changing the threshold to lower levels of SEMG.
SURFACE ELECTROMYOGRAPHIC FEEDBACK
The goal is to be able to go to full range of motion passively without causing SEMG activity.
DEVELOPMENT OF RECRUITMENT AND TIMING SYNERGIES
Isolation Training
Placing a template of the desired upward movement on the screen for the patient to copy with his or her own muscular effort can speed up acquisition of the desired recruitment pattern.31 Sometimes this learning can be encouraged by having the patient perform the recruitment pattern. side where they have already learned the desired pattern, followed by the other side.
Discrimination Training
Figure 9–10 Surface EMG recordings from the right and left upper and lower trapezius during small effort efforts, isolated to the left lower trapezius. Figure 9-11 Surface EMG recordings from the right and left upper and lower trapezius during incremental efforts to recruit and isolate the left lower trapezius.
AN EXAMPLE INVOLVING THE CERVICAL MUSCLES
SUMMARY FOR UPTRAINING
Coordinated Recruitment
Functional/Daily Activities
Treatment usually begins by teaching the patient to do "flicks". The patient is instructed to engage in short, strong contractions and to rest briefly between each action. The patient is encouraged to practice these finely tuned whipping or Kegel exercises regularly throughout the day.
PELVIC FLOOR CONSIDERATIONS
In a variation of this approach, the practitioner instructs the patient to tense and release slowly over a 10-second period. The goal is to increase the patient's awareness of the pelvic floor muscles, while strengthening them and bringing the muscles more and more under the patient's control.
BASIC DOCUMENTATION
163 Clinical documentation is critical because it allows physicians to know what has been done. It provides a basis for analysis and sharing of information with others, it allows for replication and comparison during future visits, and in many cases it is the basis for insurance reimbursement.
Documentation
The next layer of information refers to the practitioner's assessment of the patient's information. This information can help the related staff to ensure continuity of care for the patient.
ASSESSMENT CONSIDERATIONS
Recordings from the upper and lower trapezius were taken during abduction of the arms to 90 degrees. Recordings from the upper and lower trapezius were recorded during abduction and forward flexion of the arms to 90 degrees.
Relaxation or
Lower trapezius elevation/isolation training is performed using standard upper and lower trapezius electrode placement and wide-pass filter (25-1000 Hz) while sitting.
Downtraining Considerations
TREATMENT CONSIDERATIONS
Uptraining Considerations
DOCUMENTATION AS AN OUTCOME MEASURE
RELATIONSHIP OF SURFACE
ELECTROMYOGRAPHY TO OTHER MEASURES
COMPREHENSIVE LIST OF ELEMENTS TO DOCUMENT
Recording Parameters
Patient/Task Considerations
Surface Electromyography
Characterization and Interpretation
The initial frequency, the slope of the frequency during the exercise task, and the rate of recovery to the initial frequency are commonly measured (R).
ISSUES PERTAINING TO
Surface EMG values from homologous muscles are expressed as a left-right percentage change:. Larger Side – Smaller Side + Larger Side) ×100 This can be done for resting tones or from peak contraction data.
THIRD-PARTY REIMBURSEMENT
In 1996, the American Association of Electrodiagnostic Medicine (AAEM) produced a position paper stating that there are no indications for the use of SEMG in the diagnosis and treatment of nerve or muscle disorders.5 The AAEM position is correct. : Surface EMG is not intended to study muscle and nerve diseases; this should be done with needle EMG recordings. As Sihvonen, Partanin, Osmo and Soimakalio noted,6 SEMG recordings describe the flexion-relaxation phenomenon in the low back muscles better than simultaneous needle EMG recordings.
SUGGESTED READINGS
Electrical behavior of low back muscles during lumbar pelvic rhythm in patients with low back pain and healthy controls. Correlations of myoelectric asymmetry detected in patients with low back pain using portable post-style surface electromyography.
I I S URFACE E LECTROMYOGRAPHY
P AST , P RESENT , AND F UTURE
To put muscle function and the clinical use of surface electromyography (SEMG) into historical perspective, it seems prudent to use a broad nomothetic grid or conceptual framework. This will provide an in-depth background to the emergence of the clinical use of SEMG, including information on bodywork history, psychophysiology, rehabilitation, and SEMG electricity and instrumentation.
TISSUE-RELATED ISSUES
Originally, muscle assessments and treatments were done by hand; during the last century the use of electronic instruments came into play.
The History of Muscle Dysfunction and Surface
Recently, Fishbain et al.13 found that 85% of patients in pain clinics had active trigger points. Another point of view was expressed by Hubbard and Berkoff,18 who claim that SEA arises from intrafusal fibers of the muscle spindle.
THE PSYCHOLOGIC AND EMOTIONAL LEVEL
