Exploring Advanced Pelvic Floor Therapy: Biofeedback and Beyond

One of the most common questions we get asked at our Pelvic Floor PT clinic is about biofeedback, specifically:

"What is pelvic floor biofeedback and do we offer this?"

Patients often inquire if we use biofeedback because it's frequently prescribed by physicians. The short answer is both yes and no. We use biofeedback as a component of your treatment of Pelvic Floor Dysfunction, but we don’t use biofeedback devices. Let me explain why. Biofeedback is probably one of the most researched treatment methods in the physical therapy world often because it is one of the more reproducible interventions. You can create a protocol and someone can copy it almost exactly. The thing about biofeedback is that it can actually be provided in many forms: tactile (touch), visual, auditory (sound), and verbal feedback. This can range from watching yourself in a mirror during an exercise, getting tactile input from your therapist’s hands, or hearing feedback on how you completed a task or movement. That is all considered biofeedback. However, when people refer to biofeedback, they usually mean Surface EMG (SEMG) biofeedback.

What is SEMG biofeedback? This technique involves sensors that detect electrical activity in your muscles to help provide real-time information on how your muscles are functioning- essentially do they contract and do they relax. What it does not do is tell you how strong your muscles are. So the electrical activity is picked up by the sensors (either electrode pads or probes) which are connected to a device which then provides a visual display of that electrical activity to help someone learn how to better contract or relax their muscles.

Surface EMG biofeedback is a popular mode to use in the Pelvic Floor PT world because the pelvic floor muscles can be difficult to visualize. To pick up electrical activity from the pelvic floor muscles, either sensor pads are placed externally around the anus or a probe is inserted into the vagina or rectum.

Surface EMG biofeedback is most often used with individuals who have difficulty relaxing their pelvic floor muscles causing pelvic pain or difficulty when trying to poop, pee, or when trying to insert an object into the vagina or rectum such as during a medical exam or intercourse. It can also be used in someone whose pelvic floor is weak or uncoordinated to help improve the quality of a pelvic floor contraction.

Though this may appear beneficial initially, it does come with its own set of restrictions. We'll leave the judgment to you, but here is a list outlining the advantages and disadvantages of utilizing a device for biofeedback.

Biofeedback Pros:

1. It can make it easier to “see” what your pelvic floor muscles are doing in real-time if someone has a hard time feeling their muscles or if they are a visual learner.
2. You are uncomfortable with doing an internal assessment, but are okay with probes or pads.
3. An internal assessment is not advised, such as when working with children.
4. With advancing technology, there are even some devices you can purchase that can make it accessible to use in the privacy of your home. (However, without the interpretation of a Doctor of PT trained in pelvic health)

Biofeedback Cons:

1. Using this form of biofeedback can be extremely frustrating for the user because it may be difficult to contract or relax the pelvic floor and you may not visually see much of a change.
2. It’s not always accurate and can pick up electrical activity from nearby muscles (what we call “cross-talk”).
3. It can be uncomfortable to use the internal probe or pad sensors.
4. The clinic and home devices are very expensive, up to $5,000 per device.
5. There is not a lot of advanced “skill” required by the provider.
6. Sometimes, that is all that a therapy session may consist of (We have to prevent our jaws from dropping when we hear this from patients).

The reality is that even though there are many research studies conducted on the effectiveness of SEMG biofeedback and ultimately support of the use of SEMG biofeedback, the quality of research is generally poor.

Ultimately, SEMG biofeedback is not a long term solution and doesn’t get to the “why” your pelvic floor is not working correctly in the first place.

Now this may be our professional bias, but we think that there are much better skills in our Pelvic Floor Physical Therapists toolbox to help someone who is not able to relax or contract their pelvic floor. (Disclaimer: we do believe that there are some people who may actually benefit from using SEMG biofeedback, but we believe that is the minority of situations).

If you are still unsure if biofeedback is a tool that you need in your rehab process, give us a call, we are happy to discuss this with you!

Written By Dr Rebekah Wolinetz, PT, DPT, WCS, PRPC, Cert DN

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