The purpose of this article is to elaborate not on the science of neural biofeedback but rather on my experience with it as it has been prescribed for and applied to me to assist in my recovery from Guillain-Barre syndrome (GBS).

THE ONSET OF GBS

One day in May 2006, I enjoyed my usual early-morning Starbucks coffee in McLean, Va, worked out for a couple of hours at the local health club, and in the evening went shopping for groceries with my wife. Then I came home and collapsed conscious in the driveway—my legs would not support me. I was taken immediately to the Inova Fairfax Hospital and diagnosed with advanced GBS.

Various medical treatments were tried to no avail, and I slipped into unconsciousness on a respirator unable to breathe, swallow, talk, or move—retaining sensory feeling but no motor control whatsoever. From May until December, I was in two nursing homes and four hospitals fighting for medical stability having additionally contracted e-coli, staph atrial fibrillation, and pneumonia several times in addition to the epilepsy I had had from the age of 17. Hospital physicians worked to get me medically stable and wean me off respirators so that I might benefit from physical and occupational therapy. My insurance company stated that in its opinion I had plateaued, would remain paralyzed, and could benefit from no further inpatient therapy and should be shipped home and my wife trained to feed, bathe, and otherwise look after me for the rest of my life.

My physicians disagreed with the insurance company and all stated that I might benefit from a program of aggressive physical and occupational therapy, intelligently applied, gradually moving me through subacute to intensive therapy. I owe those physicians my life—a debt I can never repay but can only recognize and appreciate.

In January 2007, I was medevaced home to Ottawa, Canada, to Saint Vincent's Hospital—a chronic care facility that, together with its sister hospital, Elizabeth Bruyere, offered the medical and therapeutic care essential to the lengthy recovery from GBS.

In January 2008, I was discharged from Saint Vincent's to a nearby convalescent home still under medical supervision. By this time, I could sit in a wheelchair and was completely independent in terms of daily care.

REHABILITATION PROGRAM

In August 2007, after undergoing intensive rehab at Saint Vincent's and Elizabeth Bruyere hospitals, I was declared fit enough to progress further in terms of rebuilding strength and endurance, and regaining balance and mobility. I shall never forget my first visit to this very unpretentious rehab gym—a patient who could not stand a few months previously was hopping around the outside of the building on one leg accompanied by a PT. He was allowed to hop on the other leg but could neither stand nor walk on both. It was very intimidating. At that point, I could not stand let alone walk.

Therapists at Neurogym® have, on average, 10 years' training subsequent to degrees in physiotherapy and/or kinesiology. They are involved (through a separate operation) in designing equipment and biofeedback software for stroke or GBS rehab for institutions across North America. They are low-key and friendly in approach, but there is absolutely no slacking once your daily program begins. Rarely is there more than 30 seconds between exercises.

After an assessment of my condition, a program was developed for treatment three times per week. I was advised to give each hour 110% of effort, as the quality of a therapist's time is measured only by the progress of a patient's performance.

BIOFEEDBACK—ESSENTIAL INGREDIENTS

Determination

As with any tool, no matter how well designed, a client/patient will only get out of it what he/she puts in. One must be absolutely determined to prevail over every task set by the physiotherapist. With biofeedback, this means understanding precisely what is required, why, what the results mean in terms of improved patient performance, and, lastly, how further improvement can be achieved.

Concentration

The rehabilitation program consisted of exercises in the areas of control and coordination, active range of motion, balance, strength, and mobility. The NeuroGym® Trainer, a multifaceted biofeedback device that provides versatility through the use of various input sensors and through a video game-type training routine, was employed to improve balance, ankle and knee range of motion, joint proprioception, and trunk strength.

Typical training sessions included pressure sensors for balance biofeedback, electromyography, and joint goniometer sensors for ankle and knee range of motion and a proximity sensor for trunk strength and mobility routines. The patented NeuroGym Trainer allows therapists to target individual muscles for relaxation or activation, or to train more complex multijoint movements.

For example, one of the balance biofeedback routines was driving a car with a lateral weight shift while standing in a body-weight-support (BWS) mobility tool called a "Bungee Walker." The game was controlled by an algorithm that monitored and displayed the dynamic difference in pressure between the two pressure sensors. If needed, an additional sensor attached to the knee would be used to cue the desired knee flexion while engaging in the balance training routine.

In the exercise I am most familiar with, to improve balance, the patient is required to step on to sensors holding on to parallel bars facing a computer screen. Basically, a software program designed by Neurogym starts a ball bouncing randomly across the computer screen. The patient is required to shift weight from left to right to intercept the ball before it hits the bottom wall of the screen's frame. Variables in this exercise are duration, speed of the ball, and whether one foot or both are used. It is hard to describe the intensity of concentration and effort, not only to intercept the ball, but to properly shift weight from side to side at the same time.

Shoulders and torso must move over the hips as we flex from side to side and not just a hip shift. Posture—that is, knees slightly bent and not locked, chest out, stomach in, bottom pulled in and not sticking out, with hands hovering over the bars—is critical to remember. Regular breathing through the diaphragm must be maintained. Difficulty increases with time elapsed, but there is a finite time to "stick it out," and one must be sufficiently determined to prevail and always be ready for the therapist to require that the exercise be modified and/or repeated. This particular biofeedback technology allows for training of a complex movement routine until it is well learned (gets more automatic in its execution). This way, the degree of knee flexion, trunk position, or muscle tone in the shoulders could easily be incorporated into the balance training and learned as a synergy or system of movement.

RESULTS

The Neurogym Trainer can be used for ankle training to target the paretic muscles of the foot.

• Intensity of concentration has accustomed my brain to anticipating and shifting weight from leg to leg and improved my balance reflexes. Walking has become increasingly natural as strength and endurance have built.
• "The speed of the ball (in the Pong game) has enabled my brain to react and shift with improved control, especially with the repetition of the duration of the exercise.
• "The speed sensitivity and intensity of the weight shifts have improved my posture and balance, and this improvement has been demonstrated repeatedly in subsequent functional tasks like batting balloons or kicking a soccer ball.
• "Repetition of the shifts also has improved my balance such that shifting weight has been "remembered" by my brain.
• "Confidence. After almost 2 years in beds and wheelchairs, the combination of improved balance and mobility have, oddly enough, relaxed my brain so it can reflexively regain balance while concentrating on upright walking posture or keeping knees slightly bent or standing on one leg.

CONCLUSION

From my perspective as a client user and patient who could not stand or walk last August, biofeedback tasks have contributed to my performance where I now stand independently (balance and strength) and walk about one quarter mile without rest upright and using the hands, not to lean on, but hovering over walker handles to catch myself if my reflexes and balance should fail.

The technique that appeared most effective was the combination of lower-extremity biofeedback training—whether a balance routine or other—and a BWS technique that allowed for this training routine to be carried out in standing. This combination, very much like the combination of a treadmill and BWS, enables the process of brain plasticity that is typically associated with such dramatic improvement.

Tim Fauquier is a contributing writer for Physical Therapy Products. For more information, contact PTPEditor.