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Herman & Wallace Blog

Seeing is Believing

Using sEMG biofeedback to get real-time results

Tiffany Lee, MA, OTR, BCB-PMD and Jane Kaufman, PT, BCB-PMD are internationally board-certified clinicians in the treatment of pelvic floor muscle dysfunction through the Biofeedback Certification International Alliance. Combined, they have over fifty years of treatment experience using sEMG biofeedback. Their new course, “Biofeedback for Pelvic Floor Muscle Dysfunction”, will provide the nuts and bolts of this powerful tool so that clinicians can return to the clinic after this course with another component to their toolbox of treatment strategies.

As a clinician treating patients with pelvic floor muscle dysfunction, have you gone away from a treatment session and asked yourself ‘what else can I do for this patient?’. Have you considered adding surface EMG, often referred to as biofeedback, to your treatment plan, but aren’t sure how to go about it correctly or effectively? Perhaps you think you can’t use the sensor because the patient has pain. Maybe you think biofeedback only helps with up-training or strengthening.

So exactly what is biofeedback? Why should I consider this modality? Biofeedback provides a non-invasive opportunity for patients to see muscle function visualized on a computer screen in a way that allows for immediate feedback, simple representation of muscle function, and allows the patient and the clinician the opportunity to alter the physiological process of the muscle through basic learning strategies and skilled cues. Many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation is what helps patients really hone in on body awareness and connect all the dots. Here are a few comments that our patients have made; “I can now pay attention to my muscle while at work thanks to the visual of my muscle when sitting and standing”; “I needed to see my muscle to fully understand how to release the tension in it “; “I totally get what I need to do now that I have a clear picture of what you want”; “Seeing is believing”.

A 2017 study by Moretti, E., et al. is a great article that helps support the concept that measuring the pelvic floor electrical activity through a standard vaginal sensor is not always an option. For many patients, use of surface electrodes with peri-anal electrodes will provide the same reading and offer a more comfortable alternative for those patients who cannot use an internal sensor. This allows the clinician more opportunities to use this treatment modality with ease and assurance that the patient can learn from the visual representation of the muscle without fear of penetration from a sensor, and get great results!

In another 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 home exercise program alone.

Herman & Wallace is offering a course for clinicians in Alexandria, Virginia this June that will answer all of your questions and concerns about this fabulous treatment tool: biofeedback! This course enables the clinician to learn and practice this valuable tool and gain knowledge about the benefits of this modality, so that treatment can begin immediately with ample opportunity for patient’s positive feedback and awareness of muscle function. Participants will experience being a biofeedback practitioner and patient (using a self-inserted vaginal or rectal sensor). Participants will be administering biofeedback assessments, analyzing and interpreting sEMG signals, conducting treatment sessions, and role-playing patient instruction/education for each diagnosis presented during the many hands-on lab experiences. Biofeedback is a powerful tool that can benefit your patient population, and add to your skill-set.


Moretti, E., Galvao de moura Filho, A., Correia de Almedia, J., Araaujo, C., Lemos, C. “Electromyographic assessment of women’s pelvic floor: What is the best place for a superficial sensor?” Neurology and Urodynamics; 2017; 9999:1-7.;
Aysun Ozlu MD, Neemettin Yildiz MD, Ozer Oztekin MD, “Comparison of the efficacy of perineal and intravaginal biofeedback assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence

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Biofeedback Treatment for Dyssynergia-Type Constipation

Everyone experiences constipation, sometime! Maybe it was on vacation and you felt bloated and miserable; or when you were busy at work and had to rush to complete a task. In any event, you felt ‘awful’. Maybe you couldn’t zip your favorite jeans due to abdominal bloating, maybe you experienced lower abdominal discomfort or experienced a painful ‘movement’ once you went. There are many people who experience these symptoms and more on a daily basis. When someone finally gets the courage to see a specialist about this problem, they might be diagnosed with ‘pelvic floor dyssynergia’ or ‘muscle incoordination’.

Pelvic muscle dyssysnergia (incoordination) refers to the action that occurs in the pelvic floor musculature at the time of defecation. It can become a withholding pattern and in the case of vacation or a change in your work schedule, it can simply be tensing the muscle to avoid the bowel movement (due to inconvenience) rather than heeding the ‘call’. Over time, if this behavior is repeated, it becomes muscle memory; instead of relaxing the pelvic muscle to defecate, the patient tenses the muscle; thus the term dyssynergia or incoordination. The function of the pelvic floor for bowel function is to provide closure of the anal canal to maintain continence. The muscle should signal the rectum and the colon when to defecate and should provide opening of the anal canal by total relaxation to allow for complete and effortless elimination. A dyssynergic pattern shuts the opening of the canal by tensing the muscle to prevent elimination. Thus an incoordination.

The research by Heymen, Scarlett, Ringman, Drossman et al entitled “Randomized, Controlled Trial Shows Biofeedback to Be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-Type Constipation” supports the value of biofeedback in the treatment of this withholding pattern associated with stool elimination. This study supports the benefit of biofeedback treatments using internal sensors to provide the feedback displayed on a computer screen for visualization. This study goes on to say, “We also have shown that the machines are necessary—instrumented biofeedback is an essential element of successful training; however, there is a shortage of practitioners who are trained to provide this form of biofeedback, and there are few clinics where biofeedback instruments are available and where this form of biofeedback can be obtained”.

Biofeedback provides visual and auditory feedback of muscle tension. It 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, enabling the patient to learn how to alter the physiological process through verbal and visual cues. This mechanism allows the patient to assess muscle resting tone, creating an environment that teaches how to downtrain a tense pelvic floor while providing the means to teach co-ordination of muscle function.

In short, biofeedback treatment/training using the proper instrumentation provides the precise information necessary to change behaviors associated with tensing the pelvic floor for defecation instead of the proper relaxation of the pelvic floor for release of stool from the anal canal.

The Herman Wallace Course on Biofeedback Training for Pelvic Muscle Dysfunction provides the clinician with the proper treatment technique to use in the clinic to rehabilitate patients with pelvic floor muscle dyssynergia. Learning the proper use of biofeedback equipment and understanding the components to treating these challenging patients successfully is an essential component to this course. The clinician will learn numerous ways to teach this challenging patient population how to make this muscle function as intended, providing the patient with successful strategies for improved patient outcomes.

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