In a recent article entitled “The Effectiveness of Pelvic Floor Muscle Training in Men After Radical Prostatectomy Measured with the Insert Test,” published in the International Journal of Environmental Research and Public Health in March of 2022, the use of surface EMG biofeedback (sEMG) was one of three cohorts for men with post-operative incontinence. While all participants improved in control over micturition, the cohort of men in the group using sEMG biofeedback had the best results post-treatment./p>

So, what is it about biofeedback that improves control in patients with pelvic floor muscle dysfunction?
Biofeedback provides visual and auditory feedback of muscle activity. It is a non-invasive technique that teaches patients how to adjust muscle function, strength, and behaviors to improve pelvic floor function. The small electrical signal (EMG) provides information about an unconscious process. It is presented visually on a computer screen, giving the patient immediate knowledge of muscle function and enabling the patient to learn how to alter the physiological process through verbal and visual cues.

Kaufman states, “Without full knowledge of the use of the sEMG biofeedback equipment, many providers may miss important components to treatment.” For example, patients may inadvertently hold pelvic muscles in a chronic state of tension in an effort to avoid leakage, reducing the range of muscle excursion available for proper muscle contraction and control. Additionally, poor pelvic floor isolation can compound symptoms of incontinence when larger muscle groups such as the abdominals are co-contracting, reducing the effectiveness of the pelvic floor effort.

Importantly, biofeedback gives the skilled clinician the opportunity to evaluate proper muscle function in all three positions: supine, sitting and standing. According to Lee, “You will typically see the muscle dysfunction in the standing posture, which is not typically assessed in manual treatment.” Furthermore, in supine the muscle may not have dysfunctions and the provider will miss what happens when position is altered, and gravity negatively influences the muscle contraction.

Kaufman adds, “The only true way to determine muscle tone is through the use of sEMG biofeedback.” Manual skills alone may falsely indicate there is no muscle excursion with palpation when, in fact, the use of sEMG biofeedback reveals the presence of high tone in the pelvic muscles at rest. By restoring normal muscle resting tone the patient gains more muscle excursion and is better able to utilize and feel the muscle contract.

Case Study Example

The patient is a 63-year-old computer specialist who underwent radical prostatectomy three years ago due to prostate cancer. He has been relocated for work twice in that time and has seen two pelvic floor therapists during that period who worked exclusively with manual internal and external muscle techniques. Finally, he was referred to a biofeedback board-certified therapist who did a supine, sitting, and standing muscle assessment using two-channel sEMG biofeedback: one channel was for a rectal sensor, and the other monitored the obliques.

The "before" graph is a supine, sitting, and standing assessment. The patient is asked to perform three quick contractions, followed by a 10-second hold in each position. In the supine position, the patient demonstrated good muscle resting tone, endurance, and isolation, but once in sitting, he began to demonstrate poor pelvic floor muscle endurance, poor isolation, and higher resting tone. In standing, his pelvic floor muscle was completely overpowered by his obliques and rectus abdominis, and he had very limited pelvic muscle endurance and poor resting tone. His frustration with lack of bladder control led to withholding fluids (making symptoms worse).

Once the patient was instructed in techniques to restore normal pelvic floor muscle tone and isolated contractions using sEMG biofeedback, he began to note improved control over bladder function, and after eight visits, he was discharged from care, having achieved all treatment goals. In his "after" graph, he exhibited good muscle tone, endurance, and isolation, and did not have his abdominals overpowering his pelvic floor. He also consumed adequate water intake again but without negative effects on bladder control. He no longer needed protective undergarments.

Conclusion
A long history of scientific evidence supports using sEMG biofeedback in managing incontinence or pain symptoms. As a noninvasive, cost-effective, and powerful treatment modality, healthcare providers should consider this tool when managing pelvic floor dysfunction. Providers should be educated in adequately using this valuable modality to gain the most out of the skills and knowledge achieved through this intervention. For more information regarding courses and certification, please visit www.pelvicfloorbiofeedback.com.

Biofeedback for Pelvic Muscle Dysfunction, a self-hosted lab course scheduled for May 4, 2025, is led by Instructors Kaufman and Lee who introduce participants to the use of biofeedback when treating bladder, bowel, and pelvic floor disorders. In this course, participants learn about surface EMG biofeedback by using the equipment on themselves to experience dynamic muscle assessment in supine, sitting, and standing positions. This dynamic course also includes behavioral strategies for relearning proper muscle control for improved pelvic floor function.

Instructors Kaufman and Lee have over fifty years of combined experience using this amazing clinical tool. This treatment approach uses sEMG biofeedback to visualize muscle dysfunction, then allows for proper training and education to re-establish proper muscle movement patterns, enabling patients to gain control over function and realize they can succeed in improving symptoms. Lee adds, “Patients are constantly validating the usefulness of this modality by reaping the benefits of skilled training and behavior modification strategies.”

References:

1. Cram, J. R., & Kasman, G. S. (2011). The basics of surface electromyography. In E. Criswell (Ed.). Cram’s introduction to surface electromyography (2nd ed., pp. 3–7). Jones and Bartlett
2. Kaufman, J., Stanton, K., & Lee, T. E. (2021). Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Biofeedback, 49(3), 71-76.
3. Shelly, Beth & Kaufman, Jane (2023). Foundations of Pelvic Floor Muscle Assessment Using Surface Electromyography. APTA Academy of Pelvic Health Physical Therapy.
4. Szczygielska D, Knapik A, Pop T, Rottermund J, Saulicz E. (2022). The Effectiveness of Pelvic Floor Muscle Training in Men after Radical Prostatectomy Measured with the Insert Test. Int J Environ Res Public Health. 2022 Mar 2;19(5):2890. doi: 10.3390/ijerph19052890. PMID: 35270582; PMCID: PMC8910379.

AUTHOR BIO
Tiffany Lee, OTR, OTD, MA, BCB-PMD, PRPC

Tiffany Lee holds a BS in OT from UTMB Galveston (1996), an MA in Health Services Management, and a post-professional OTD from Texas Tech University Health Sciences Center. In 2004, she received her board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance. She is a Herman and Wallace Pelvic Rehab Institute faculty member and teaches biofeedback courses. She has been treating pelvic health patients for 25 out of her 30-year career. Her private practice in San Marcos, Texas, is exclusively dedicated to treating urinary and fecal incontinence and pelvic floor disorders. Her continuing education company, Biofeedback Training & Incontinence Solutions, offers clinical consultation and training workshops. She also enjoys mentoring healthcare professionals working toward their BCIA certification.

Surface EMG is the only modality that can isolate the active component of tone and is, therefore, a very valuable tool in the assessment of patients with altered tone conditions. However, it is the most misunderstood modality in pelvic health therapy. Rarely do practitioners see a topic so argued in pelvic rehabilitation as surface EMG biofeedback. Some practitioners boldly state they are for or against it on their social media accounts and clinic pages. Therapists are not questioning the use of biofeedback with neurologic or orthopedic applications, so why is it such a polarizing topic in pelvic health? The Pelvic Rehab Report sits down with faculty members Tiffany Lee and Jane Kaufman to discuss the tool they love. These two instructors have over 50 years of combined experience using biofeedback and have been teaching biofeedback board certification courses together for the past 16 years.

Biofeedback provides visual and auditory feedback of muscle activity and is a non-invasive technique that allows patients to adjust muscle function, strength, and behaviors to improve pelvic floor function. The small electrical signal (EMG) provides information about an unconscious process and is presented visually on a computer screen, giving the patient immediate knowledge of muscle function and enabling the patient to learn how to alter the physiological process through verbal and visual cues. Jane Kaufman explains “Many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation helps patients hone in on body awareness and connect all the dots." Muscle evaluation through digital exam offers strength but does not appropriately address electrical activity such as resting tone and the ability to recruit or release tone in the muscle. The use of biofeedback addresses the specificity of muscle contraction and release, offering an additional view of muscle function.

In a 2020 research study by Pilkar et al., clinicians reported sEMG barriers of use, which included limited time and resources, clinically inapplicable sEMG system features, and the majority of clinicians' lack of training and/or confidence in the utilization of sEMG technology. This research also noted technical challenges, including the limited transfer of ever-evolving sEMG research into off-the-shelf EMG systems, nonuser-friendly intuitive interfaces, and the need for a multidisciplinary approach to accurately handling and interpreting data.

One barrier may be the price of a biofeedback unit. Tiffany Lee recommends using a 2-channel sEMG biofeedback hand-held unit with the software on a laptop or computer. In fact, to become board-certified in pelvic floor biofeedback, the Biofeedback Certification International Alliance (BCIA) requires a 2-channel EMG system with software. If you use a hand-held one-channel unit, the patient will have difficulty seeing the muscle activity and the coordination between the abdominals and pelvic floor. This prevents meaningful treatment as the patient cannot understand or interpret the LED bars on the machine (and often, the therapist cannot understand either). In truth, the benefits outweigh the cost of the equipment. You can cover the unit's cost and software to visualize muscle function and tone within a few treatments. Training is another issue; you need proper training in the modality to start utilizing biofeedback in your clinical setting. Most therapists have never been adequately trained. If they take a course where the instructor doesn’t believe in the benefits of biofeedback, they feel negatively toward a modality they have never personally explored. Biofeedback relies on a skilled clinician to interact with the patient, give verbal cues, ensure that the proper muscles are contracting and relaxing, and must be used in conjunction with their other skills and knowledge.

Think of sEMG biofeedback as one tool in your toolbox. Tiffany shares, "In a study by Aysun Ozlu MD et al., the authors conclude that biofeedback-assisted pelvic floor muscle training, in addition to a home exercise program, improves stress urinary incontinence rates more than a home exercise program alone." She continues, "Biofeedback is a powerful tool that can benefit your patient population and add to your skill set.

The acceptance of sEMG biofeedback in rehabilitation requires a unit (with software and sensors), training, and a multidisciplinary approach. Used correctly, it can positively impact patient performance and care in the clinic. Keep in mind that sEMG is a non-invasive technique. It has already shown great promise in neurorehabilitation and has been a widely utilized tool to assess neuromuscular outcomes in research. Jane Kaufman concludes, "Biofeedback treatment/training using the proper instrumentation provides the precise information necessary to change behaviors." This allows the patient to recognize that ‘yes, they are in charge of this muscle and that they can achieve success in overpowering the symptoms.’ Biofeedback routinely allows patients to understand that they are empowered to heal themselves with the tools you offer. They are in charge of their bodies and the outcome of treatment. It is also an important tool to use with patients who have experienced trauma and who are not ready to participate in manual therapy, and it is valuable for the pediatric population as well. Tiffany adds, “This modality can bring new business to your clinic. My local GI and colorectal providers often refer up to 5 new patients a week to my practice.

There is a long history of scientific evidence supporting the use of sEMG biofeedback in managing incontinence or pain symptoms. As a noninvasive, cost-effective, and powerful treatment modality, healthcare providers should consider this tool when managing pelvic floor dysfunction patients. Providers should be educated in the proper use of this valuable modality to gain the most out of the skills and knowledge that can be achieved through this intervention. For more information regarding courses and certification, please visit www.pelvicfloorbiofeedback.com.

Tiffany asked several PTs and OTs who have been to the board certification courses what they love about biofeedback. Here are a few answers

• “Biofeedback empowers my patients and gives them the confidence that they are actually doing their exercises and relaxing correctly! I’ve had nothing but positive feedback from patients, and it’s such a great tool to have as a pelvic floor therapist.”
• “My patients really love it, and they ask for it. I especially see the value for dyssynergia work on bearing down and learning eccentric abdominals and relaxed pelvic floor muscles. For men, I work on relaxing in standing and toileting postures if they can’t empty their bladder.”
• “Ultimately, the treatment needs to be meaningful to the patient. Biofeedback can complement other treatments. Their needs come before ours. We should offer all of our patients the ability to control their own muscles and SEE how to do it.”
• “After ONE session with a 5-year-old with constipation, mom called me in sheer excitement, screaming over the phone that he pooped on the potty!!! Something he has NEVER done before. Biofeedback helped him find and coordinate the potty muscles and tummy muscles, and this made a huge difference for him!”
• “Becoming certified in biofeedback has only been positive for me. My patients feel that the initial sEMG evaluation sets the stage for my care plan, and my discharge reassessment is a tangible reflection of their progress. Not to mention its strength as a marketing tool.”

Jane Kaufman adds “Biofeedback in treatment has been a game changer. Using this tool as a foundation for treatment in my clinic allowed my practice to grow, thrive, and achieve great acclaim in our region and beyond. It is not unusual for patients to travel several hours to seek treatment because of the empowering effect the biofeedback visual had on their understanding of their dysfunction.”

Biofeedback for Pelvic Floor Muscle Dysfunction is scheduled for July 28^th and December 7^th, 2024, and provides a safe space for clinicians to learn and practice this valuable tool. Registrants will need equipment to participate in this online course and will learn about the benefits of using this modality in their clinical practice.

In this course, Tiffany and Jane guide participants through learning to administer biofeedback assessments, analyze and interpret sEMG signals, conduct treatment sessions, and role-play patient instruction/education for each diagnosis presented during the many hands-on lab experiences.

References:

1. Use of Surface EMG in Clinical Rehabilitation of Individuals With SCI: Barriers and Future Considerations Rakesh Pilkar, Kamyar Momeni, Arvind Ramanujam, Manikandan Ravi, Erica Garbarini, Gail F. Forrest. Front Neurol. 2020; 11: 578559. Published online 2020 Dec 18. doi: 10.3389/fneur.2020.578559 PMCID: PMC7780850
2. Comparison of the efficacy of perineal and intravaginal biofeedback-assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence. Aysun Ozlu MD, Neemettin Yildiz MD, Ozer Oztekin MD. Neurourol Urodyn. 2017 Nov;36(8):2132-2141. Epub 2017 Mar 27. doi: 10.1002/nau.23257 PMID: 28345778.
3. Cram, J. R., & Kasman, G. S. (2011). The basics of surface electromyography. In E. Criswell (Ed.). Cram’s introduction to surface electromyography (2nd ed., pp. 3–7.) Jones and Bartlett.
4. Kaufman, J., Stanton, K., & Lee, T. E. (2021). Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Biofeedback, 49(3), 71-76.
5. Shelly, Beth & Kaufman, Jane (2023). Foundations of Pelvic Floor Muscle Assessment Using Surface Electromyography. APTA Academy of Pelvic Health Physical Therapy.

AUTHOR BIOS

Tiffany Lee, OTR, OTD, MA, BCB-PMD, PRPC

Tiffany Lee holds a BS in OT from UTMB Galveston (1996), an MA in Health Services Management, and a post-professional OTD from Texas Tech University Health Sciences Center. In 2004, she received her board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance. She is a Herman & Wallace Pelvic Rehab Institute faculty member and teaches biofeedback courses. She has been treating pelvic health patients for 25 out of her 30-year career. Her private practice in San Marcos, Texas, is exclusively dedicated to treating urinary and fecal incontinence and pelvic floor disorders. Her continuing education company, Biofeedback Training & Incontinence Solutions, offers clinical consultation and training workshops. She also enjoys mentoring healthcare professionals working toward their BCIA certification.

Jane Kaufman, PT, M.Ed, BCB-PMD

Jane has been practicing PT for more than fifty years. She is a graduate of the Ithaca College Physical Therapy program and earned her master’s degree at the University of Vermont. In her early career, she practiced in outpatient settings, skilled nursing, and acute rehabilitation. Jane’s career began at Columbia Presbyterian Medical Center and progressed to the University of Vermont Health Network where she supervised the Department of Physical Therapy’s outpatient services. In the late 1990s, Jane became intrigued with pelvic floor muscle dysfunction, evolving to a quarter-century career in this highly specialized field.

In 2001 she began her career as a sole practitioner in pelvic floor muscle dysfunction and in 2003 established Phoenix Physical Therapy, PLC with a staff of clinicians specializing in the treatment of pelvic floor dysfunction, incontinence, and pelvic pain for all genders and all ages. In 2005, Jane became certified in the use of surface EMG biofeedback for pelvic floor muscle dysfunction (BCB-PMD ) from the Biofeedback Certification International Alliance. She sold her practice in 2022, having established a renowned reputation in Vermont, upstate New York, regionally, nationally, and internationally. Post Phoenix, Jane continues to offer workshops for other healthcare providers in the use of biofeedback for pelvic muscle dysfunction, and mentors healthcare professionals around the world toward certification in this field through the Biofeedback Certification International Alliance. Jane teams with Tiffany Lee, OTR, OTD through Biofeedback Training and Incontinence Solutions (www.pelvicfloorbiofeedback.com).

Jane has recently begun a consulting practice helping adults with pelvic floor muscle dysfunction issues and has continued helping children/teens through her new practice, PottyTime Physical Therapy (www.pottytimephysicaltherapy.com). In addition to her practice and teaching, Jane has participated in research through the University of Vermont Health Network on pelvic organ prolapse, incontinence, and sexual dysfunction. She has authored an article published in the online international journal Biofeedback and was a co-author in the APTA self-study manual for Foundations in Pelvic Floor Muscle Assessment using Surface Electromyography with Dr. Beth Shelley, PT, DPT, WCS, BCB-PMD. She is a Herman & Wallace Pelvic Rehabilitation Institute faculty member and teaches biofeedback courses through this company. Jane may be reached by email at: This email address is being protected from spambots. You need JavaScript enabled to view it.