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BIOFEEDBACK
Sponsor:InstituteofSpinalCordInjury,Iceland

BRUCKERMETHOD
1) Introduction
2) How It Works
3) Biofeedback for SCI
4) Questions and Answers
5) Conclusion
6) Availability
INTENTIONCONTROLLEDMYOFEEDBACK(IMF)

Introduction: Biofeedback is a subtle training technique used to

enhance mindbody control. By providing subjects with external audio or

visual feedback of subtle nervous signals that reach the muscles, using
electrodes to sense the signals, biofeedback provides a means for identifying,
strengthening, and using these signals. Through this technology, biofeedback
lets subjects know when they are changing their physical responses such as
nerve signal strength, body temperature, blood pressure, or heart rate in
desired directions. This information can be used to teach individuals to
better control their body.
Under certain conditions, biofeedback can assist individuals with SCI to
regain or improve functional usage of motor nerve cells in the brain, brain
stem, and spinal cord, which can lead to improved use of disabled limbs.
Dr. Bernard Brucker, Founder of the Biofeedback Laboratory at the University
of Miamis School of Medicine, developed an internationally recognized
biofeedback method that uses precise techniques to restore
lost functions in those with neural impairment, called the
Brucker Method. According to Brucker, his aim in developing
his method was to improve the lives of those with neurological
motor impairment by providing a bridge between neuroscience
and rehabilitation.
Biofeedback was initially viewed with skepticism by traditional medicine.
However, repeated studies confirmed that individuals could change both
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voluntary and involuntary responses after being fed back information that
revealed what was occurring in their bodies. After treatments, patients
retain the ability to repeat learned responses at will, without visual or audio
feedback.
In 1969, the use of audiovisual information to train subjects to alter blood
pressure, heart rate, muscle tension, and brain activity was first termed
biofeedback. O. Hobart Mowrer pioneered the use of instruments to
control bodily functions in 1939, using alarms triggered by urine to stop
children from bedwetting. Biofeedback first gained the publics attention in
the late sixties, when it was used to demonstrate the biophysical selfcontrol
of yogis in altered mental states.
Biofeedback has been used to treat migraine headaches, tension headaches,
chronic pain, digestivesystem disorders, urinary incontinence, high blood
pressure, cardiac arrhythmias, attention deficit hyperactive disorder,
Raynauds disease, epilepsy, SCI, stroke, traumatic brain injury, cerebral
palsy, and various movement disorders.

How Biofeedback Works

A reinforcing stimulus is roughly the same as a reward. If a person
does something and receives a reinforcer, he will probably do the
same thing again the next chance he gets. Richard Malott, (1972)
Biofeedback is a form of operant learning; psychologist Leland Swenson says
of EMG biofeedback as an operant training technique:
EMG biofeedback has been extended into the medical areas of
deficient neuromuscular control. Inglis, Campbell, and Donald (1976)
reviewed applications of EMG biofeedback in treating peripheral nerve
muscle damage, the effects of strokes, partial paralyses, and cerebral
palsy (early brain damage having a motor component). They cite
considerable evidence to suggest that patients can learn to gain more
control over the involuntary activity of voluntary muscles. This
neuromuscular reeducation approach has been successful in restoring
function to paralyzed limbs where some neural control remains. Within
a couple of hours, those patients who had at least a few intact nerve
endings were producing sufficient motor unit action potentials from
these surviving nerve endings to achieve large percentages of normal,
voluntary muscle functioning. The various studies reported 50% to over
85% of patients benefited from such treatments. [Applications of
OperantRelated Learning Principles to the Real World, Leland
Swenson]
For SCI applications, the Brucker method of biofeedback operant training
uses electromyography (EMG), which senses motor action potentials (nerve
impulses or signals) with far greater precision and sensitivity than the user
can. Electromyography therapy determines the bioelectrical function of a
patient's muscles, which indirectly reveals the functional condition of the
spinal cord and brain.
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During biofeedback treatment, the patient is requested to perform intended

movements. Using a movable graph on a computer screen, EMG provides
visual feedback of neural signals that reach the target muscles. The subject
may need repeated attempts to find a neural pathway that delivers a
signal to target muscles. But even then the signal is often too weak for the
subject to sense.
Once a neural path is found, the therapist directs the subject to make the
EMG graph grow. This can only occur by increasing the strength of the
motor signal that reaches the muscle. However, because the subject may not
sense the signal, or signal variations may be too slight to be felt at first, the
moving chart provides the reinforced stimulus necessary for operant learning
to occur.
Thus, visual feedback teaches the subject how to reproduce, maintain, and
control EMG responses for maximum improvement in muscle function. This
information, combined with behavioral conditioning techniques and
rehabilitation, helps subjects reeducate their muscles. The level of control
gained in one session is the starting point for the next.

Biofeedback for SCI:

For SCI, the Brucker Biofeedback Technique

uses the Neuroeducator 3 Electromyography (EMG) Biofeedback System,
which allows therapists to identity subtle motor connections between the
brain and the body that survive SCI, or that have slowly repaired or rebuilt
since being damaged. This information allows therapists to design
individually customized plans aimed at restoring or improving voluntary
muscle control.
The Brucker technique is the only biofeedback protocol specifically designed
to enhance neural conduction and functions in subjects with neurological
injury and disease. Unlike general uses of biofeedback to enhance relaxation,
or to control blood pressure or heart rate, biofeedback for SCI requires
equipment sensitive enough to monitor neural signals to within one percent
of a normal signal. In addition, for SCI applications biofeedbacktrained
therapists should know which muscles are needed to regain specific motor
functions, the signal strength needed for specific muscles to function, and
techniques for helping the subject find and develop these signals.
People with SCI have regained much lost motor function after biofeedback
training. The results sometimes appear as miraculous. People who were told
that they would never walk or use their hands have regained the ability to
walk or feed themselves. Restored functions become natural through
practical use. However, motor improvements through biofeedback training
require specific physical conditions:
1.A neural connection must exist between the brain and the muscle
(or muscle group) that is desired to move. Such connections might
have survived initial SCI, or they may have repaired over time, or
they may be the spinal cords attempt to rewire itself through
existing connections.
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2.The patient must be aware and able to mentally respond to

therapist directions.
3.Muscular atrophy or contractures cannot be so severe that theyre
unable to be corrected. Electrical stimulation therapy may be
needed to strengthen or rebuild atrophied tissues, allowing them to
fully benefit from biofeedback. Because physiatrists can be
reluctant to prescribe such therapy to retard or reverse atrophy
when no obvious muscle contractions are present, biofeedback
evidence of an existing signal can be used to show a need.
4.Biofeedback can be used to monitor any neural signal provided that
an external electrode can be positioned to sense and relay the
signal to an external device thats able to represent the signals
presence and strength. Although biofeedback can be used to
improve functions in the hands or feet, muscles in fingers or toes
can be too small for electrodes to fit.
Understanding biofeedback potentials and limitations reveals the importance
of maintaining muscle tone, flexibility, and bone density through personal
care. The above requirements are needed not only in using biofeedback to
train the body in using existing, but disused neural connections, but will also
be needed for individuals with SCI to benefit from emerging treatments that
repair or regenerate the spinal cord.
Sources of neural connections through the spinal cord after SCI include, for
example, existing pathways, alternate pathways, damaged pathways that
spontaneously repair over time, pathways that spontaneously rewire over
time, and surgically reconstructed pathways
According to Brucker, it is extremely rare that all of the cords neural
connections are lost due to SCI. A complete classification of SCI (compared
to an incomplete injury) is a functional description of neurological
symptoms, rather than a physical description of the spinal cord itself. Nerve
connections between the brain and muscles below the level of injury often
survive SCI, but signals over these connections are too weak to be felt in a
neurological examination or to move affected limbs.
In addition to Bruckers observations of biofeedbacks clinical use, studies
involving Transcranial Magnetic Stimulation provide supporting evidence. Dr.
G.A. Delaney and colleagues (London, Canada) found that axons could survive
through the injury site in patients with longstanding SCI, preserving "axonal
integrity in descending motor tracts in the face of extensive functional loss."
Similar to the brain, redundancy is believed to be part of the spinal cords
design. Several neural pathways may connect the brain to specific targets in
the body, rather than one. But a lifetime of repeated use conditions our
brains to see certain pathways as the connection for certain uses. Brucker
makes the analogy of a favorite route between the workplace and home. If
construction closes the road, we still go home provided we find and learn to
use an alternate route.
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Over time, repairs may naturally occur to demyelinated axons, or broken

axons may find and remake lost connections in the injured spinal cord. Axon
regrowth is limited by the extent of gliosis (the formation of the glial scar
that occurs during acute SCI) and the presence of inhibitory molecules in the
spinal cords extracellular matrix, which were released due to damage to
myelin sheathing.
Finally, medicine is beginning to test methods for repairing or regenerating
the damaged spinal cord. The brain may find it difficult to find and use newly
created neural connections, or repaired connections that have been
chronically turned off. For all these potentials, biofeedback provides a
means for finding, improving, and using these connections.

Biofeedback for SCI: Questions & Answers

1) How does biofeedback work? Biofeedback is not a treatment in the sense
that something is done to the subject. Similar to learning to ride a bicycle,
biofeedback teaches users to sense and make use of potential abilities
through experience. For example, its impossible to explain the balance
needed to ride a bicycle to someone else. They need to feel it for themselves
but once felt and controlled they retain the skill for life.
In practice, biofeedback for SCI uses external electrodes to sense subtle
neural signals that reach the muscles when the subject tries to move them.
The electrodes relay this information to a device thats able to represent the
signal and its strength visually, or with sound. The Brucker approach usually
presents a line graph that changes with increasing signal strength.
Subjects are directed to contract the monitored muscle. The EMG system is
able to sense and reveal slight neural signals that the subject may not feel.
Once a signal is found, the subject is instructed to try to focus not on the
arm or leg, but on the graph, while they attempt to make the graph grow. If
sounds are used, theyre instructed to turn the sound on or off. For example,
when attempting to decrease spasticity a subject may be directed to turn a
sound off, which would correspond to controlling the unwanted spasticity
signal. When directed to increase a motor signal the subject would try to
turn the sound on.
With trial and error and repetition, subjects may find more effective
pathways for producing desired results. Once these pathways are found and
used, the brain remembers where they are and how to use them.
Improvements gained in one biofeedback session are the starting point for
the next.

2) How soon will the therapist know if improvements are possible? A

biofeedbacktrained therapist can tell during the first treatment whether
neural connections exist for each muscle tested. The likelihood of functional
improvements depends on the strength of motor signals that reach the
muscles. For example, the quadriceps requires roughly 14% of a normal motor
signal to trigger voluntary contractions. If 10% percent of a normal signal
reaches the muscle when the subject attempts to move it, prior experience

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suggests that the movement threshold might be reached in the first or second
biofeedback session. More sessions are needed if the initial signal is lower,
but still strong enough to suggest that a muscles functional threshold might
be reached. If no signal can be found, or if no improvement can be made on
trace signals, it is unlikely that the muscles functional threshold will be
reached at that time. A clinical study involving one hundred subjects with
upper extremity SCI reported the following:
A significant increase in EMG activity occurred from the triceps
after one biofeedback treatment session and further significant
increases in EMG activity occurred after additional biofeedback
treatment sessions. Initial muscle strength and initial EMG
levels were not determining factors for response to the
biofeedback. The results suggest the efficacy of biofeedback for
increasing voluntary EMG responses in long term spinal cord
injury patients.
3) Does injury level or neurological completeness limit potential
benefits? Biofeedback therapy can lead to functional improvements in
subjects with SCI regardless of level of injury or completeness. Moreover,
MRIs are unable to accurately predict outcomes of biofeedback treatments,
because they are unable to determine the neural conductivity. Subjects with
injuries evaluated as complete have made substantial improvements
through biofeedback. Whereas others with slight to moderate incomplete SCI
have improved only slightly. According to Brucker, it is rare that biofeedback
therapy fails to exert some degree of positive effects.
4) Does time post injury affect possible effects? Biofeedback treatment
outcomes for those with SCI can be affected by time post injury for the good
or bad. Patients who had little neural sparing through the injury site soon
after injury can have considerable disused connections ready to be found and
used, once enough time elapses to permit neural repair, or remodeling. On
the down side, too much time post injury contributes to muscle atrophy,
contractures, and loss of bone density; these can all adversely affect an
individuals ability to benefit from biofeedback. For example, if a tendon
becomes to too contracted, it may be unable to respond to biofeedback
identified and strengthened signals.
5) What degree of improvement is typically seen in patients with SCI?
Brucker estimates that 98% of individuals with SCI who undergo his method
improve at least one vertebra level of functionality; therefore the condition
of an individual with cervical C7 SCI might improve to that generally found in
those with thoracic T1 injury. Ninefive percent of his patients improve two
vertebra functional levels, and 85% improve three. Improvements greater
than this are too erratic to predict. However, biofeedback improvements
may occur in functions controlled by nerves that leave the cord far below the
subjects lesion, before being seen in functions controlled by nerves that exit
the cord just below the injury site.
Depending on which muscles can be fired through biofeedback and
strengthened through rehabilitation, it may be possible for previously
wheelchairusing individuals to stand and ambulate. Specific muscles
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(quadriceps) are needed to stand, and others (hip flexors) are needed to
walk. However, the use of braces or adjusted patterns of gait might allow a
subject to stand or ambulate even if control of the quadriceps and hip
flexors is not achieved. This also applies to the muscles of the calves, feet,
and ankles, or to the upper extremities. In other words, a BFBtrained
therapist will try to improve as many functions as possible. But if some motor
functions do improve, while others do not, improvements in limb
function might still be gained.
6) How long does a typical session last for a subject with SCI? One hour.
7) Has biofeedback led to positive effects in SCI patients for urinary,
bowel, respiratory, spasticity/clonus, or pain issues? Biofeedback can
produce positive effects on urinary incontinence, bowel control, respiration,
spasticity, and clonus. It is ineffective for treating SCIrelated chronic pain.
Improved muscle tone and control of abdominal muscles can indirectly
improve bowel and bladder control. Spasticity and clonus often decrease
when improvements are made in voluntary motor signal strength. Previously
ventilatordependant subjects have improved the use of intercostal muscles,
which assists breathing with the upper chest cavity (as opposed to
diaphragmatic breathing), allowing these individuals to become ventilator
independent.
8) How many sessions are usually required to achieve maximum results?
Fifteen sessions are normally advised for a course of biofeedback treatment
for SCI.
9) What physical factors determine the outcome of biofeedback
treatments? To be effective, neural pathways must be exist between the
brain and muscles that control desired functions. Neural signals over these
connections may be weak or the connection may be dormant. But a pathway
must exist for biofeedback to exert an effect. Target muscles must be able
to respond to neural signals. Excessive atrophy and tendon contractures can
prevent the use of limbs, regardless whether a neural connection is found or
strengthened.
10) Can Biofeedback reverse muscular atrophy? Muscle mass may be
improved if biofeedback therapy leads to functional use. Moderate to severe
atrophy may require the use of therapeutic electrical stimulation to rebuilt
atrophied muscles along with biofeedback. However, an initial biofeedback
evaluation can reveal if nerve signals are present in atrophied muscles that
might lead to functional improvements once the muscles are rebuilt.
11) Are additional rehabilitation regimens recommended for biofeedback
subjects? Biofeedback is more effective when combined with other forms of
rehabilitation. For reasons discussed before, it is recommended that
individuals considering biofeedback attempt to maintain flexibility, bone
density, and muscle mass. If biofeedback therapy succeeds in identifying and
strengthening neural pathways, physical rehabilitation may optimize their
functional use.
12) Are followup treatments indicated once improvements plateau? Once
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improvements plateau, further biofeedback therapy is unlikely to lead to

additional gains. However, because neural repairs in the damaged spinal cord
can slowly occur over time, periodic biofeedback evaluation may reveal new
potentials for functional improvements.
13) Has biofeedback been used with other functionenhancing modalities
or reparative/regenerative interventions? Biofeedback has been used
successfully with therapeutic electrical stimulation to maintain or restore
muscle mass and standard physical rehabilitation practices. Because
biofeedback offers an effective means for finding new neural connections
and training the patient in their functional use, it should synergistically
enhance the potential benefits accruing from the many functionrestoring
therapies emerging throughout the world.
14) Is Biofeedback ineffective for any functions commonly lost or impaired
through SCI? Biofeedback is ineffective for restoring sensation lost through
SCI. Nor does it alleviate chronic pain due to spinal cord damage.
15) What contraindications exist for biofeedback? Because biofeedback
therapy does not do anything to the body, few contraindications exist.
However, because resulting functional improvements can require strenuous
physical effort, individuals interested in biofeedback may need to be
aerobically fit.
16) Where is the Brucker biofeedback method offered? The procedure is
available in several locations in the U.S., Europe, the Middle East, Central
America, South America, and Asia (see below).

Conclusion: In conclusion, Brucker emphasizes: Many individuals

facing permanent functional losses due to central nervous system (CNS)

damage have neurological potential for greater functional recovery, even
long term post onset. Biofeedback techniques can be extremely powerful in
gaining this increase in function through more efficient use of the CNS, but
only if applied properly.
In addition to improving the lives of individuals with SCI, Brucker believes
that biofeedback offers a valuable means for maximizing functional gains
from neural repairs whether they occur naturally, or result from clinical
treatments. He notes: Recent findings in neurological and behavioral
sciences have shown that CNS cells, if damaged, have potential for
remyelination and axonal repair which can take place years post damage
from injury or disease. It is also now known that the CNS can have both
dendrite and axonal sprouting in its attempt to regain integrity. While the
functional correlates of such neural repair were once thought to be
automatic, it is becoming clear that to maximize this neural potential,
specific learning techniques at the neuronal level are necessary. Advanced
biofeedback is the technique best suited for maximizing this potential.

AVAILABILITY
MainCenter
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BruckerBiofeedbackLaboratory,UniversityofMiamiSchoolof
Medicine/MJHHA,5200NE2ndAve,Miami,FL33137
(telephone:3057623882email:eroberts@mjhha.org.
OtherU.S.Centers
FloridaHospital,5165AnansonSt,Orlando,FL32804(407
3037600).
CoraRehabilitationClinic,527ELongAve,NewCastle,PA
16101(7246544545).
St.David'sRehabilitationCenter,1005E32ndSt,Austin,TX
78705(5124767111).
MaryFreeBedRehabilitationHospital,WealthySE,Grand
Rapids,MI49503(6162420360).
InternationalCenters
NeurologicalEducationCenter,BeijingRehabilitationCenter,
BeijingShijingshanDistrict,BadachuRd,Beijing,China(010
88961133,ext2204).
Dr.BernardBruckerRehabilitationCenter,SantaAnna
University,RuaVoluntarriosdaPatria#257,Santana,Sao
Paulo,Brazil02011000(551121758050).
HospitaldeNino,Apartado4087,Zona5,Panama,Republicof
Panama(0015072251583).
JerusalemCommunityHealthCenter,30TachkemoniSt,PO
Box6851,Jerusalem,Israel(01197225381820).
OrthopadischeKlinikMunchenHarlaching,Zentrumfur
Kinderorthopadie,LeitenderArztDr.med.PeterBernius,
HarlachingerStrasse51,81547Muchen,Germany(0896211
2071).
MallyaHospital,No2,VittalMallyaRd,Bangalore,India560
001(91802277979).

INTENTIONCONTROLLEDMYOFEEDBACK(IMF)
GermanscientistUlrichSchmidtdevelopedIMFtherapy,whichis
beingusedinanumberofclinics(e.g.,www.imftherapy.co.uk)to
treatavarietyofneurologicaldisorders,includingSCI.Likeother
biofeedbacktherapies,IMFisbasedonthescientificallyprovenfact
thatinmostspinalcordinjuries,eventhoseclinicallyclassifiedas
complete,someintact,albeitperhapsdormant,neuronsstill
transversetheinjurysite.Throughappropriaterehabilitative
programsandbuildinguponinherentplasticity(i.e.,adaptability)of
thenervoussystem,thesesurvivingneuronslaythefoundationfor
newfunctionrestoringneuronalnetworks,pathways,and
connections.
WithIMF,residualnervesignalsgeneratedbythementalintention
tomovemusclesbelowtheinjurysitearerecordedatthose
muscles.TheIMFdeviceamplifiesthesefaintimpulsesandthen
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sendstheamplifiedsignalsbacktothetargetmuscles.With
practice,thisprocessbuildsupnascentfunctionrestoringnetworks
and,inturn,voluntarymusclemovementandstrength.Unlike
passiveFESmusclestimulation,thepatientsintentionisthedriving
forcebehindrestoredfunction.
Atthe6thEuropeanTraumaCongress(May2004),Schmidtand
colleaguespresentedtheresultsofastudyevaluatingtheeffectsof
IMFtherapyinsubjectswithparaplegia:
19paraplegicpatientsrangingfrom1monthto43yearsafter
spinalcorddamageperformedIMFtherapywiththeaimofachieving
betterstabilityintheirbody.Afteronemonth18patientshadbetter
proprioceptivefeedbackandonepatienthadnochange.Aftertwo
months11patients(60%)wereabletointensifyvoluntarymuscle
activity.Afterthreemonths3patients(15%)wereabletostandand
walkoncrutchesorwithametalwalkeroneofthem43yearsafter
spinalcorddamage.

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