Expert Series

6

In the evolving field of health care, bio-feedback, as a treatment and evaluationtool, is playing an increasingly moreimportant role. Biofeedback is used by adiversity of health professionals to treatan ever-lengthening list of conditions.Health professionals such as physical andoccupational therapists, psychiatrists,psychologists, nurses and physicians invarious specialties have come to usebiofeedback either independently or asan adjunctive technique with positiveresults.

The Expert Series is an on-going series ofinterviews with leading clinicians in thefield of biofeedback lending their insightsand techniques they have acquiredthrough their many years of practice.

Thought Technology is very pleased to bepart of this educational project. Since1974, Thought Technology has beencommitted to making biofeedback moreaccessible through innovation intechnology and educational initiatives.

The Expert Series interviewed Ron Fuller,PTA, BA, a physical therapy assistant,who practices at Healthsouth Rehab-ilitation Hospital in Concord, NewHampshire. Ron is the aquatic specialistfor Healthsouth Corporation (nationally),as well as an adjunct faculty at severalcolleges where he teaches aquatictherapy and advanced orthopedicconditions to PT and PTA students. He ison the teaching faculty of AquaticConsultants of Georgia (ACOG), as well asteaching workshops for the BiofeedbackFoundation of Europe. He has authoredseveral articles on aquatic rehabilitationand lectures nationally and inter-nationally on aquatic therapy fororthopedic conditions and the use ofaquatic biofeedback in the treatment ofupper and lower extremity conditions.

Please tell us about your work in using SurfacePlease tell us about your work in using SurfacePlease tell us about your work in using SurfacePlease tell us about your work in using SurfacePlease tell us about your work in using Surface

Electromyography (SEMG) biofeedback forElectromyography (SEMG) biofeedback forElectromyography (SEMG) biofeedback forElectromyography (SEMG) biofeedback forElectromyography (SEMG) biofeedback for

rehabilitation and how you tied it into aquatics.rehabilitation and how you tied it into aquatics.rehabilitation and how you tied it into aquatics.rehabilitation and how you tied it into aquatics.rehabilitation and how you tied it into aquatics.

I started using SEMG many years ago for land-based ortho-

pedic disabilities and was familiar with its use in the reha-

bilitation realm. After attending an aquatic seminar and

talking with one of the speakers, a question was posed to

me, “How can we gather quantitative data from aquatic

rehabilitation?” I immediately thought about how I utilized

the information from SEMG on land and wondered if I could

somehow tie it in to aquatic therapy. After several months

of experimenting with different types of bio-occlusive

dressings, I finally found a covering that gave me the bar-

rier I needed to utilize SEMG in the water. This technique

allowed me the opportunity to treat clients with a multitude

of diagnoses from orthopedic to neurological, reconstruc-

tions to spinal cord injuries, etc. I can cus-

tomize my rehab to treat specifics, whether

it be facilitation or inhibition of specific

muscles or muscle groups. Our clinic has

more referrals for aquatic therapy because

of our ability to customize and record

aquatic rehabilitation using aquatic bio-

feedback.

AQUATIC BIOFEEDBACKAQUATIC BIOFEEDBACKAQUATIC BIOFEEDBACKAQUATIC BIOFEEDBACKAQUATIC BIOFEEDBACK

Ron Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BA

Ron Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BARon Fuller, PTA, BA

Ron Fuller, PTA, BA isRon Fuller, PTA, BA isRon Fuller, PTA, BA isRon Fuller, PTA, BA isRon Fuller, PTA, BA is

the Aquatic Specialistthe Aquatic Specialistthe Aquatic Specialistthe Aquatic Specialistthe Aquatic Specialist

for HealthSouth Corpo-for HealthSouth Corpo-for HealthSouth Corpo-for HealthSouth Corpo-for HealthSouth Corpo-

ration. Ron teachesration. Ron teachesration. Ron teachesration. Ron teachesration. Ron teaches

aquatic therapy ataquatic therapy ataquatic therapy ataquatic therapy ataquatic therapy at

several colleges and isseveral colleges and isseveral colleges and isseveral colleges and isseveral colleges and is

a faculty member ofa faculty member ofa faculty member ofa faculty member ofa faculty member of

the BFE.the BFE.the BFE.the BFE.the BFE.

Exp

ert

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es

6

What can youWhat can youWhat can youWhat can youWhat can youtell us about thetell us about thetell us about thetell us about thetell us about theuse of SEMG inuse of SEMG inuse of SEMG inuse of SEMG inuse of SEMG inthe water?the water?the water?the water?the water?Studies haveshown that earlyuse of surface EMGin combinationwith exercise can be useful inrehabilitation more than justexercise alone.2,3,5,10 Severalclinicians theorized that theuse of surface EMG in thismanner may help clients reha-bilitate by, “increasing neuraldrive to the quadriceps andovercome inhibitory processesoccurring in response to painand edema.”1 It seemed natu-ral to combine aquatic therapyand SEMG as an adjunct toland-based therapy. By utiliz-ing several physical propertiesof water (i.e. buoyancy andturbulence drag) the poolbecomes the perfect mediumin which to unload the joint,relieve pain, decrease effusionand initiate exercise during theacute phase.

Have there been anyHave there been anyHave there been anyHave there been anyHave there been anystudies on the use ofstudies on the use ofstudies on the use ofstudies on the use ofstudies on the use ofaquatic SEMG?aquatic SEMG?aquatic SEMG?aquatic SEMG?aquatic SEMG?For several years, a union ofthe two modalities, biofeed-back and aquatic therapy, hadbeen casually explored, andonly superficially re-searched.6,7,8,9 Not until re-cently has there been a fo-cused effort to combine andfunctionally utilize the waterand surface EMG. The firstresearch article that I collabo-rated on was with Brian

Awbrey, MD, show-ing that the tech-nique of aquaticbiofeedback wasvalid and reproduc-ible. It also showedthe therapist couldassess their client’sprogress quantita-

tively, allow the client to effec-tively train while in the pooland ultimately, customize thetreatment program to fit theindividual needs of the client.4

Since that first article I havepublished several other arti-cles regarding aquatic biofeed-back.

Can you tell me aboutCan you tell me aboutCan you tell me aboutCan you tell me aboutCan you tell me aboutsome of the other articlessome of the other articlessome of the other articlessome of the other articlessome of the other articlesthat you have publishedthat you have publishedthat you have publishedthat you have publishedthat you have publishedon aquatic biofeedback?on aquatic biofeedback?on aquatic biofeedback?on aquatic biofeedback?on aquatic biofeedback?There are a couple of usefulpapers in the APTA AquaticJournal, Volume 9, Number 1(Fall 2001), An Aquatic andLand-Based Physical TherapyIntervention to Improve Func-tional Mobility for an Indi-vidual After an Incomplete C6Spinal Cord Lesion”, Vol. 7,Number 1, Spring 1999) enti-tled, “Activity Levels of theVMO Muscle during a SingleLeg Mini Squat on Land and atVaried Water Depths”.

For general reading on AquaticBiofeedback Technique I rec-ommend a few articles thatwere published in SportsMedicine Update magazine(Vol. 15, Number 2, 2001),“Aquatic Biofeedback Treat-ment of PFPS”, ADVANCE for

PT’s & PTA’s (Nov.2nd, 1999),PT/OT TODAY (June 5th, 1999)and “Rehab and TherapyProducts in Review” (March/April 1999). Most recently inADVANCE for Directors ofRehab. (Sept. 2000, Vol. 9, No.9) there was an article onAquatic Biofeedback.

Why haven’t we heard ofWhy haven’t we heard ofWhy haven’t we heard ofWhy haven’t we heard ofWhy haven’t we heard ofaquatic SEMG until now?aquatic SEMG until now?aquatic SEMG until now?aquatic SEMG until now?aquatic SEMG until now?There are two reasons whyaquatic SEMG has played arelatively minor role in musclerehabilitation and re-educa-tion. One was the inherentdifficulty of the therapist tomonitor SEMG activity in apool environment. The otherreason was a lack of clinicianswilling to take their land-basedSEMG expertise and equip-ment into the pool area. Al-though various authors havepublished articles regardingthe use of aquatic SEMG, veryfew use it on a daily basis inthe rehabilitation of theirclients.

Aquatic biofeedback utilizesthe same techniques andprocedures as its land-basedcousin. Skin preparation andelectrode placement are stillimportant, however the criticalstep is the application of awaterproof barrier to seal theelectrode site. The waterproofbarrier is the key to aquaticbiofeedback. It enables thetherapist the opportunity tospecifically direct treatmentsand to collect quantitative datawhile the client exercises in

Aquatic Biofeed-

back utilizes the

same techniques

and procedures

as its land-based

cousin.

Expert Series

6

the water. Since the surfaceEMG unit is hand-held andpowered by a 9-volt battery,the threat of electrocution iseliminated and site infiltrationby water remains nothing morethan a momentary light tingle.The possibility of saturating anexpensive surface electrodehowever remains a more realis-tic hazard. The client performstheir exercise routine while‘wired-up.’ The therapist di-rects and records specificevents of the treatment ses-sion.

Why is aquatic SEMGWhy is aquatic SEMGWhy is aquatic SEMGWhy is aquatic SEMGWhy is aquatic SEMGbecoming so popular?becoming so popular?becoming so popular?becoming so popular?becoming so popular?The addition of aquatic therapyin rehabilitation can provide anenvironment in which therapycan be initiated earlier, land-based exercises can be mas-tered sooner, and specificskills can be advanced quicker.Aquatic biofeedback, however,brings to the exercise regimenspecificity, control, quantitativemeasurements and clienteducation. In the real world,clinicians have time con-straints as well as insuranceconsiderations to keep inmind. The need to validatetreatments or prove progress isan important part of the totalrehabilitation picture. Quicktreatment and rapid rehabilita-tion is imperative. Aquatictherapy offers the therapist theopportunity to start exercisesimmediately; aquatic biofeed-back allows the client to knowhow to do the exercises cor-rectly.  

Is it true that the aquaticIs it true that the aquaticIs it true that the aquaticIs it true that the aquaticIs it true that the aquaticbiofeedback is hard to do?biofeedback is hard to do?biofeedback is hard to do?biofeedback is hard to do?biofeedback is hard to do?It used to be true when Istarted out and had to use theprotective wrap method. Theidea evolved from my searchfor an easy-to-use, waterproofseal for the SEMG sensor.Thought Technology and theirresearch team developed aneasy-to-use SEMG add-on.AquaSense™ connects to anyof their SEMG sensors to adapttheir use to the pool environ-ment.  This unique designallows the therapist to takeadvantage of the well docu-mented benefits of the waterenvironment easily and con-sistently for their biofeedback-assisted therapy sessions.AquaSense™ can be applied inseconds by attaching thesensor as the therapist nor-mally would. 

How do most clients reactHow do most clients reactHow do most clients reactHow do most clients reactHow do most clients reactto aquatic biofeedback?to aquatic biofeedback?to aquatic biofeedback?to aquatic biofeedback?to aquatic biofeedback?At first, they are somewhatskeptical. However, after theysee the benefits derived fromjust a one-hour session, theyare more comfortable wiringup for their pool session. Theprocess of attaching the elec-trodes and donning theAquaSense™ sock (or glove)takes about three minutes sothere is very littleset-up time thatcuts into yourtreatment time.AquaSense™comes in varioussizes so you can

find the right fit for your cli-ents’ arm or leg.

Aquatic therapy allows me theopportunity to start treatingmy clients sooner by utilizingthe physical properties ofwater. Aquatic biofeedbackstreamlines my focus, en-hances my treatment skills,and gives me quantitativeuseable data to assist myclients’ rehabilitation.

1. Cram, J.R., Kasman, G., (1998). Knee Dysfunction.Clinical Applications in Surface Electromyography.(Aspen Publishers). Pg. 366

2. Draper, B., Ballard, L. (1991). Electrical stimulationversus electromyographic biofeedback in the recoveryof quadriceps femoris muscle function following ACLsurgery. Phys Ther. 71: 455-463.

3. Draper, V. (1990). Electromyographic biofeedback andrecovery of quadriceps femoris muscle functionfollowing ACL reconstruction. Phys Ther. 9: 11-17

4. Fuller, R.A., Awbrey, B.J., Dye, K.K., Cook, N.R. (1999).Activity level of the VMO during single leg mini squatson land and at varied water depths. Journal of Aquatic Physical Therapy. 7 (1): 13-18

5. King, A.C., Ahles, T.A., Martin, J.E., White, R. (1984). EMGbiofeedback-controlled exercise in chronic arthritic kneepain. Arch Phys Med Rehabil. 65: 341-343

6. Nuber, G.W., Jobe, F.W., Perry, J., Moynes, D.R., Antonelli,D. (1986). Fine wire electromyography analysis ofmuscles of the shoulder during swimming. Am J SportsMed. 14: 7-11

7. Pink, M., Pery, J., Browne, A., Scovazzo, M.L., Kerrigan, J.(1996). The normal shoulder during freestyle swimming:an electromyographic and cinematographic analysis oftwelve muscles. Am J Sports Med. 19(6) : 569-576

8. Poteat, A.L., Redfield, D.S., Erlandson, M.O., Becker,K.M., Hemmesch, R.A. (1996). Surface EMG: a methodto examine land versus water shoulder exercises onmuscle activity. (unpublished research). St. Paul, MN: St.Paul Ramsey Medical Center.

9. Poteat, A.L., Redfield, D.S., Erlandson, M.O., Becker, K.M., Hemmesch, R.A. (1996). Quantification of aquatic physical therapy water-based methods: Part I: Surface

electromyography. Journal ofAquatic Physical Therapy 4(1) :13-17

10. Sprenger, C.K., Carlson, K., Wessman, H.C. (1979). Application of electromyographic biofeedback following medial menisectomy. Phys. Ther. 59: 167-169

The addition of

aquatic therapy in

rehabilitation

provides an envi-

ronment in which

therapy can be

initiated earlier.

AquaSense - The first commercially available aquaticbiofeedback rehabilitation solution.

Thought Technology’s AquaSenseTM is a watertightenclosure designed specifically for use with ourSEMG sensors. With AquaSenseTM you can nowcombine the benefits of aquatic therapy with musclere-education. AquaSenseTM helps you improve thequality of client treatment, opening new therapeuticopportunities.

Call us regarding upcomingAquatic Biofeedback

workshops in your area!

AQUATIC REHABILITATION USING SEMGProduct Features:

• Slips easily and comfortably over the limb.• Made of rugged surgical latex.• Nonskid grips help prevent slipping.• Patented integrated pump provides a

watertight seal.• Comes in a variety of sizes for arms or legs.• Works with all Thought Technology

encoders.

Thought Technology Ltd.2180 Belgrave Avenue Montreal, QC, H4A 2L8, Canada

Tel: 1-800-361-3651 • 514-489-8251 Fax: 514-489-8255

e-mail: mail@thoughttechnology.com

http://www.thoughttechnology.com

™

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AquaSense™

Keeping your sensors dryAquaSense™ comesin a range of sizesfor arms and legs.

Dive into AquaticBiofeedback™