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”
EMG is a helpful tool to observe pelvic floor muscle activity and how it is influenced by everything from regional musculoskeletal factors and mucosal health, to client motor control, awareness, and comfort.
In this post I will discuss the case of one client who was referred for dyspareunia treatment, and whose SEMG findings are outlined in Figures 1-3. She had validated test item clusters for right hip labral tear as well as femoral acetabular impingement, in addition to right sided pelvic floor muscle overactivity and sensitivity with less than 3 ounces of palpation pressure.
The figures below demonstrate peri-anal SEMG response of pelvic floor muscles within a single treatment session, which included sacral unloading in supine as well as hip joint mobilization to demonstrate the relationship between her pelvic floor and her hips. Our focus for this SEMG downtraining treatment was to enable her to understand the connection between her pelvic floor muscle holding patterns and her body’s preferences to remain out of ranges of motion that impinged and irritated her hip.
By creating a clear understanding of how the client could 'listen" to her muscle activity via SEMG (as well as her kinesthetic awareness of her own comfort), she began to understand the difference between body and hip position, her pelvic floor muscle activity, and her pain during intercourse.
Pelvic floor motor control with normalized respiration, orthopedic considerations of sexual activity, and other physical therapy as well as multidisciplinary treatments were integrated into her ability to resume intercourse. The lens of SEMG, however, was a powerful tool to help her make the connection between her hip and its influence on her pelvic floor overactivity and symptoms.
Musculoskeletal co-morbidities in pelvic pain are common, requiring the clinician to have a set of test item clusters to scan and clear key structures, as well as the ability to convey this information without creating distress to the client when positive findings are discovered. For example, labral tears and subchondral cysts are common findings in asymptomatic clients and physical therapy plays a key role in reducing client fear, avoiding symptom provocation, reducing regional muscle overactivity, as well as facilitating movement and strengthening in painfree ROM.
Although this case example describes intraarticular hip dysfunction as a driver of this clients PFM overactivity, Finding the Driver in Pelvic Pain is a course that is designed to cover comprehensive key test item clusters for a fundamental pelvic pain scan exam of intrapelvic as well as extrapelvic drivers, to ensure the clinician understands the contributing factors that can influence or be influenced by the pelvic floor. This course is best suited for physical therapists and physical therapist assistants who are looking to create an organized approach to their scan exam for pelvic pain. For non-physical therapists, this can be a powerful introduction to the skill set and vocabulary needed to create a multidisciplinary team with a PT in the treatment of these clients.
PFM EMG at rest in supine, knees bent, feet on table (peri-anal SEMG electrode placement)
Same position, only with sacral unweighting by placing folded towels on either side of sacrum, unweighting all pressure from sacrum. Immediate report of increased comfort in buttocks, hips and pelvis.
Supine, sacrum unweighted as in figure 2, after multidirecitonal hip joint mobilizaiton.
Groh, Herrera. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun; 2(2): 105–117. Published online 2009 Apr 7. doi: 10.1007/s12178-009-9052-9
Yosef, et al. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol. 2016 Dec;215(6):760.e1-760.e14. doi: 10.1016/j.ajog.2016.07.023. Epub 2016 Jul 18.