What question did this study set out to answer?

The study aims to evaluate the enjoyment, dosage, muscle activation, and arm function outcomes of gamified electromyographic biofeedback in individuals with tetraplegia from SCI.

April 17, 2026Open Access

Gamified electromyographic biofeedback for people with tetraplegia from SCI is enjoyable, results in high-dosage therapy, increases muscle electrical activity, and may improve arm function, a pilot study

Key Points

The study aims to evaluate the enjoyment, dosage, muscle activation, and arm function outcomes of gamified electromyographic biofeedback in individuals with tetraplegia from SCI.
Participants used wearable sensors to measure EMG from paretic muscles while playing interactive games.
Sessions lasted 40 minutes, targeting four muscles with 10-minute activities per muscle.
Participants completed the Physical Activity Enjoyment Scale and tested muscle strength before and after sessions.
Chronic participants performed the Capabilities of Upper Extremity Test at baseline and conclusion.
Over 300 muscle repetitions were achieved in most sessions, with some exceeding 1,500.
31 out of 34 participants reported high enjoyment based on PACES scores.
Average muscle voluntary contraction improved by 23.8% per session (p < 0.001).
2 of 3 chronic participants showed improvements in arm function exceeding minimal clinically important differences.

Abstract

Individuals with tetraplegia due to spinal cord injury (SCI) place a high priority on improving arm function for their independence and quality of life. Animal studies have shown a therapeutic benefit of much higher therapeutic dosages than obtained in clinical practice. Electromyographic (EMG) biofeedback is validated in people with SCI and can produce high dosage therapy. The goal of this pilot study is to test if gamified electromyographic (EMG) biofeedback can address this need by quantifying (1) participant enjoyment, (2) dosage of muscle activations, (3) increases in muscle activation, and (4) improvements in arm function measured with the Capabilities of Upper Extremity Test (CUE-T). Adults with traumatic complete and incomplete cervical SCI with volitional arm movement wore wearable sensors measuring EMG from paretic upper extremity muscles to control interactive games. Participants engaged in repetitive muscle actions for 10 min per muscle, targeting four muscles per 40-minute session. Participants with an acute SCI completed 1–2 sessions, while participants with a chronic SCI completed 8–12 sessions. All participants completed the Physical Activity Enjoyment Scale (PACES), and had MVC assessed at the beginning and end of each session, with EMG recorded during gameplay. Chronic participants performed the CUE-T at baseline and at the conclusion of their biofeedback sessions. The study enrolled 28 acute participants and 6 chronic participants. Most participants performed more than 300 repetitions in a session, with some achieving over 1,500. The majority (31/34) of participants reported enjoying the games (PACES > 63). The average MVC improved by 23.8% per session (p 7.7). Gamified EMG biofeedback with wearable sensors produces an enjoyable, high-repetition therapy of over 300 repetitions in most compared to the 20–50 repetitions seen in usual therapy. Participants showed improvements in muscle EMG activity. Chronic participants may even improve their arm function as measured by the CUE-T. No adverse effects were seen except self-resolving muscle soreness. This therapy has the potential to enable people with SCI to perform fun and effective home therapy, which will be further assessed in future studies.

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