**2.1. At the clinic**

global challenge, since it affects up to three-quarters of the overall population [1]. It is the most common cause of severe long-term pain and disability in Europe with a tremendous

**1.** people with musculoskeletal pain are frequent visitors to primary health care centres, hos-

**3.** MSDs are the major cause of work absence or productivity loss, disability pensions, early

**4.** the estimated losses resulting from a decreased productivity due to MSD injuries repre-

**5.** back, shoulder, and neck pain affect nearly 40% of adults reporting MSD pain worldwide.

For these reasons, MSDs are recognized as a priority by the EU Member States and European Social partners, according to European Agency for Safety and Health at Work [4]. Physiotherapy is the main non-pharmacological clinical MSD treatment. However, a host of

**3.** patients spend considerable amounts of time visiting the clinics to receive treatment, often

For these reasons, the majority of patients abandon or must repeat treatment within a year. The low success rate and inconsistency of treatments for MSD pain lead to increased financial

According to the National Health Service (NHS) in England, physiotherapy practice to address MSDs can include a variety of different treatment and preventive approaches, depending on the specific condition. On a first session, the physiotherapist will assess and determine together with the diagnostic provided by the doctor (if the patients visited a doctor before) as

The main approaches generally used by physiotherapists are (1) education and advise (i.e. providing general and specific guidance on ways to improve well-being, by taking regular exercise or to reduce risk of pain or injury during daily life activities); (2) manual therapy (e.g. mobilization, massage, and manipulation of body tissues and structures to relieve pain and stiffness, improve blood circulation and promote relaxation, and improve movement); (3) electrotherapy (e.g. transcutaneous electrical nerve stimulation—TENS, ultrasound, iontophoresis, and treatments alike); (4) movement and exercise (e.g. specific training activities to

**2.** within the EU, MSDs represent 15–20% of consultations in primary care [2];

social and economic impact, as evidenced by the following:

retirement, and increasing need for social support;

sented 2.9% of the GDP in the US from 2004 to 2006 [3];

common problems plague physiotherapy treatment today, namely.

**2.** time to recovery (i.e. treatments take too many sessions);

costs, both for the patient and for health reimbursement systems.

to what kind of intervention the patient may need.

help improve mobility, function, and decrease pain levels).

pitals, and paramedical institutions;

60 Biofeedback

**1.** inconsistent outcomes;

during working hours.

**1.2. Treatment methodologies**

Biofeedback is a general concept that involves every external input given to the patient in order to enable him/her to learn how to change physiological activity, to facilitate his/her performance, and improve health and performance, where sEMG is also included [8]. For the case of MSDs, this technique is particularly useful to give the correct perception about the dynamics of the muscle groups that are being exercised. As a result of the conditionings introduced by the disorders, very often patients perform a specific task or movement full of compensations,1 with a low participation of the muscle groups needed to correctly converge to a full recovery scenario with mobility patterns that can be considered clinically normal.

It is common to see patients alone in the physiotherapy gym, performing the exercises in a highly distorted way (e.g. as fast as they can), which often contributes to worsen their condition. Using sEMG biofeedback equipment helps to prevent this kind of situations, ensuring that patients have specific indications to follow and get motivated by visual and acoustic aids, while knowing that in the end the physiotherapist will have access to all that was done when the patient is alone. This puts the patient in charge and also increases his/her responsibility regarding the recovery process (**Figure 1**).

At a clinical level, sEMG biofeedback is first used as an assessment tool, allowing an objective analysis of movement patterns (e.g. activation sequences and timings), levels of electrical

<sup>1</sup> Compensation occurs when the muscles responsible for a specific movement are not working (due to pain, neurologic reasons, or simply by altered movement patterns related with specific sport gestures or daily activities), and other surrounding muscles replace their activity, in order to allow functionality.

activity and muscles participation in different movements. This gives the first information, combined with other tests performed, to define an exercise plan and specific exercises to help decrease symptoms. After this initial step, we get to the main purpose of the tool, which is to guide exercise execution in real time. Specific targets can be defined to challenge the patient and to make him/her climb to the next step in the recovery process. Recorded data from assessment and training can be compiled into a final report so that progress in-between rehabilitation sessions at the clinic is objectively tracked.

technology can be made very friendly and easy to use; however, until recently, the devices were too cumbersome, complex and not so adaptable to the independent use by the patients. Furthermore, it was difficult to access the home sessions remotely and be aware of what was

Bridging the Clinic-Home Divide in Muscular Rehabilitation

http://dx.doi.org/10.5772/intechopen.76790

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In the following sections, we describe how home training is no longer isolated and unsupported. Patients can exercise at home with the confidence that the way they are mobilizing their muscles is correct and not potentially harmful. Home exercises are described as effective in accelerating the rehabilitation process [9]. In our approach, the process starts from a faceto-face session, where all sEMG assessments are performed by the physiotherapist, a treatment plan is designed, initial exercises are performed and a home plan is defined in order to continue what was started at the clinic. Once at home, the patient logs in his/her mobile app, checks where to apply the EMG sensors guided by visual cues on the app, reviews the list of exercises through example videos and executes all defined exercises supported by real-time biofeedback. In the end, a direct message can be sent to the physiotherapist via the application, to express how easy/hard was the session, how is the patient feeling, and so on, so the therapist can make sure the patient performs the exercises correctly and in an adequate quantity and change the prescribed plan if needed. Regular visits to the clinic must be scheduled,

This is an important paradigm shift to the way physiotherapy can be seen and approached. As presented next, a modern infrastructure has been designed especially to support home rehabilitation sessions in an integrative way, by means of (1) wearable and user-friendly miniaturized sEMG sensors; (2) intuitive mobile apps prepared to easily guide the patients on the execution of the pre-configured exercises prescribed by their physiotherapist (in a serious game approach); (3) objective reports shared with the physiotherapist with the possibility to send messages about the session by the patient, which promotes a fluid communication between patient and physiotherapist; (4) online dashboards to access the home training results and make changes to the prescription, so that the next time the patient logs in the

**Figure 1.** Electromyographic (EMG) biofeedback software with a concentric circle graphic relative to one muscle, to guide the patient to execute the exercise correctly and within the needed time. The goal is to contract the muscle in order to put the red dots inside the circle, making them green. The opposite, to help the muscle to relax, is also possible.

done at home by the patient.

according to patient-specific needs and progress.

The use of sEMG biofeedback equipment is associated to a 50% faster recovery time in conditions such as shoulder impingement and scapular instability (average of seven sessions), and in a reduction of the recurrence of 75% after 2 years follow-up (9% recurrence) [5].
