Biofeedback: A Tool in the Toolbox

By Bryn Zolty, PT

As rehabilitation therapists we all learn techniques to evaluate and treat patients.  Often we refer to all these techniques as tools in our toolbox. Like a good carpenter, we strive to have a toolbox full of techniques so that we can provide the best care for each patient.  We all have our favorite tools. With clinical experience and evidence based research, therapists may pick one tool more often for the job than another. However, I feel strongly that a tool will work better if you have been properly trained and had lots of practice with that tool.  This applies to the use of biofeedback, specifically in this case, for pelvic muscle dysfunction. It is a tool in our toolbox. Not the only one, but one of my favorites. And a tool supported by medical evidence.  

I thought it was a great tool from the first time I was exposed to it during a pregnancy and postpartum course.  As students in the course, we tried birthing positions to see if our muscles could relax. Relaxation of your pelvic muscles is highly desirable in order to have tissues that will stretch as a baby is being delivered.  A better position means less injury to mom, less problems with incontinence and prolapse later. But everyone had a different position in which they could relax. This meant that we could not teach one position to everyone, but use our biofeedback tool to determine which position worked for each person.  This is patient-centered care because we treat each patient as an individual. ​

​I was introduced to biofeedback in other pelvic courses, but again, just enough to see different ways it was helpful.  I had my clinic get one and immediately started using it. I used it to teach patients how to kegel or relax. Then I saw that you could take a 5 day course, mentoring hours, an exam, and be certified through the Biofeedback Certification International Alliance (BCIA).  In fact, parents of children with pelvic dysfunction, were asking for a biofeedback certified practitioner. After going through this certification process, I understand why they want the certification. It shows them that I didn’t just get exposure of a machine, but have shown to be proficient in its use.

Through the mentoring process I learned many more uses for biofeedback for pelvic floor dysfunction.  I learned to teach the patient how to use their muscles during tasks, functional movements, strengthening, coordinating a bowel movement breath, and more! These are things I have always taught, but now the patient and I could actually observe the muscle recruitment during the teaching.  I could adjust my cueing and teaching to fit that person.  

Not many patients walk into the office complaining that they have problems with their pelvic floor just laying in bed.  But lying on your back is the only position many therapists use the biofeedback in. I use the biofeedback in a toileting position, during the movement that makes them leak urine, and in poses to relax or strengthen.  It helps patients find out what their body is doing during the task that is most meaningful to them. Again, this is patient-centered care.    

What is biofeedback?

Biofeedback is a tool to help a patient change behaviors or responses. More technically, it is electromyography, EMG.  It measures muscle recruitment. That means if done correctly, it measures a targeted muscle when you activate it. If I put the surface electrodes (small stickers) on a muscle and ask you to squeeze or contract, the graph on the computer will show if you are able to contract the muscle.  In pelvic floor biofeedback we have the option of surface electrodes or internal sensors. This is always a discussion with the patient to find out what method they are most comfortable with.   


Am I appropriate for biofeedback?

Often a patient is told at a doctors appointment that they need biofeedback.  I receive many scripts that request biofeedback for muscle training. The doctor may have concerns about the patient performing the correct program.  Also, many gastrointestinal doctors have done testing that shows that there is incoordination of the pelvic floor during attempted bowel movements. This means the patient squeezes their muscles when they should relax, making it difficult to evacuate stool. 

Your first visit with a therapist is an evaluation.  One of the many things we look for is your ability to coordinate your muscles.  This means we have you contract, relax, and isolate muscles. If you are having difficulty with verbal and physical cueing, you may be appropriate.  

Research shows that almost half of patients being told to kegel will actually push and bear down instead of squeezing and lifting.  It is also common that patients will contract their abdomen at the same time and have difficulty isolating the pelvic floor. Also, a cause of constipation can be pelvic floor activation when the muscles should be relaxing.  

A pelvic physical therapist has special training to perform internal pelvic floor evaluations.  This internal evaluation provides us with valuable information to help you with your dysfunction.  However, it is so important for a therapist to present all the options for evaluation and treatment.  Not everyone needs or is comfortable with internal vaginal or rectal muscle evaluation. I like to inform each patient of all the information I can gather from each technique and let them decide.  It is their care, their body, and their decision. Surface EMG can offer the patient and therapist a look at activation and coordination and help their symptoms without any internal contact. Some patient populations that may benefit from biofeedback because internal contact isn’t possible include:

• Pediatric cases
• Cultural reasons
• Victims of abuse/trauma
• Severe pain
• Fear
• Immediately post op or post partum without clearance for internal
• On pelvic rest
• They do not want internal

Pelvic floor therapists need to be incredibly sensitive.  Our patients share with us things their family may not even know.  We need to build trust before many patients feel comfortable, if ever, with internal evaluation.  This does not mean they do not get therapy! I see a huge relief in many of my patients when I explain that they do not ever need to have internal treatment.  I tell them what I could do instead, and the pros/cons. Many of them choose biofeedback.  

What is a session like?

Prior to the biofeedback session, I discuss all the options.  First we discuss sensor options. Most of my patients choose the surface electrodes, but internal sensors are an option that can then be used for biofeedback and if stimulation is part of their plan of care.  If you are a child or have severe internal pain, the surface electrodes are used. These are placed peri-anally. That means on either side of the anus.   

I usually have my patient put their pants back on, or a gown if they prefer for the session.  We move around and the more comfortable a patient is the better the session. I will cue the patient through long or short squeezes, coughing, relaxation, bowel movement breathing, or whatever it is that we identified in the evaluation or we find on the biofeedback that needs to be addressed.  I try different cues, screens or tones to get the desired outcome. I often find that the patient can achieve the goal on their own by monitoring the screen. If you figure out a problem on your own, you usually remember it better! Many patients need just one session to get started, some patients require more.  It all depends on the patient because patient-centered care is so important.   

Are there side effects? Can I get hurt?

Patients need to know that the biofeedback detects your muscles’ activity.  No electrical charge goes into you during biofeedback. The machine will not hurt you.  Squeezing muscles repeatedly can create muscle soreness. Just like after a workout at the gym.  If increased resting tension is seen on the biofeedback and pain is associated with kegels, then I focus on muscle relaxation, physiological quieting, body scans, posture, etc.  But it is possible that you are sore from exercising the muscles.   

Courses and certification

There are several organizations that offer coursework for therapists.  My path took me to Herman and Wallace for most of my pelvic floor training.  I recently took a more biofeedback focused course from Biofeedback Training and Incontinence Solutions.  I have been fullfilling my mentoring requirements through Tiffany Lee from Biofeedback Training and Incontinence Solutions.   For information on coursework and mentoring, visit www.pelvicfloorbiofeedback.com.  The BCIA offers certifications in different fields of biofeedback including pelvic muscle dysfunction.  They require didactic course completion, mentoring, certification exams, and hours. Their website includes information for therapists hoping to become certified, as well as a board certified practitioner database for patients to locate certified therapists at www.BCIA.org.