Biofeedback Mastery

Biofeedback Mastery

Have you ever wondered what Biofeedback is all about? Uncover these unique information on Biofeedback! Are you in constant pain? Do you wish you could ever just find some relief? If so, you are not alone. Relieving chronic pain can be difficult and frustrating.

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Practical Aspects of Biofeedback Therapy for Pelvic Floor Dysfunction

Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. A solidstate system is preferable to a water-perfused system because there is no distraction or embarrassment from leakage of fluid and the patient can be moved to a sitting position without adversely affecting calibration. Surface electromyography instrumentation is widely used and proven effective for biofeedback training. Although not suitable for...

Efficacy of Biofeedback Literature Review

When interpreting the reported clinical outcomes, one should keep in mind that there are no established guidelines regarding the number of sessions, teaching methods, clinician qualifications, type of equipment used, or patient inclusion criteria, nor are there subjective or objective data used to establish success. Hyman et al.4 reported in their critical review that perhaps most importantly, there is no identified standard for training biofeedback clinicians to treat pelvic floor disorders. As with any therapy, the competence of the clinician is likely to have a significant impact on the outcome of treatment.4 Norton and Kamm2 reported that many patients lack the motivation or are unconvinced about the possible value of what they perceive to be simple exercises therefore, the results of treatment are largely patient dependent, unlike drug or surgical therapy. Gilliland et al.5 reported that patient motivation and willingness to comply with treatment protocols was the most important...


In biofeedback, patients are taught to consciously regulate unconscious body functions. By learning to depress the activity of the sympathetic nervous system, improvements can be realized in blood circulation and pressure, heart rate, digestion, and spastic conditions of the stomach and colon. The sympathetic system is for emergencies, a fight-or-flight situation, and it is thought that this system is also activated when anger and anxiety remain unexpressed which can keep the body in a constant state of tension. As a result, organs become chronically stressed and eventually give way to illness and disease. Biofeedback uses computers to give instant feedback on brain wave activity, respiration, skin temperature, electric resistance of skin and muscle tension, and can also monitor conditions of the bladder, esophagus motility, stomach acidity, and of the rectal sphincter in cases of incontinence. Patients are taught through various techniques to effect a desired response while computers...

Biofeedback Defined

Biofeedback is defined as a a group of therapeutic procedures that utilizes electronic instruments to accurately measure, process, and give feedback to individuals and their therapists, meaningful physiological information with educational and reinforcing properties regarding both normal and abnormal neuromuscular and autonomic activity, both normal and abnormal, in the form of analog, binary, auditory and or visual feedback signals.1 This process helps patients develop a greater awareness of, and confidence in, voluntary control over physiologic processes. Using biofeedback instruments without proper cognitive preparation, instruction, and guidance is not appropriate biofeedback therapy.1

Biofeedback Sessions

The initial session begins with a history and description of the anatomy and physiology of the bowel, bladder, and pelvic muscle function using anatomic diagrams and visual aids. This is followed by a description of the biofeedback process, instrumentation, and PMR exercises. Results are not immediate as with any exercise program, muscle improvement requires time and effort. The initial goals of isolated pelvic muscle contractions are established and an example of an sEMG tracing showing efficient muscle function is reviewed. Patients are given instructions on proper insertion of the internal sensor and remain fully clothed during the session. They are placed in a comfortable semi-recumbent position for training. Surface electrodes are then placed on the right abdominal quadrant along the long axis of the oblique muscles, used to monitor abdominal accessory muscle use. The cables are attached to the SRS Orion PC 12 (SRS Medical Systems, Inc., Redmond, WA) multimodality instrumentation...

Device Therapy for Stress Incontinence

The majority of patients with stress urinary incontinence are successfully managed with surgery however, not all patients desire surgery, nor are all patients operative candidates. Nonsurgical treatment options include pelvic floor muscle exercises, biofeedback, electrical stimulation, and pharmacologic agents. Anti-incontinence devices serve as another alternative to treat these patients, and include both vaginal and urethral prosthesis (Table 6-1.1 Figure 6-1.1).

Psychosocial treatment

Early psychological treatments for GAD consisted mostly of non-specific interventions such as supportive psychotherapy, relaxation training, and biofeedback. In general, those treatments were not very effective. More recently, treatments have been developed that specifically target cognitive (e.g. worry) and behavioural (e.g. avoidance) features of GAD. These treatments are typically administered in a dozen or so sessions, and can be conducted in group or individual formats. In controlled trials, these newer cognitive and cognitive-behavioural treatments have been more effective than no treatment or a psychological or drug placebo treatment and at least as effective as benzodiazepines (for a review, see Barlow et al.(59> ). Attrition is low (10-15 per cent), and reductions in anxiety average about 50 per cent, with gains being maintained at follow-up. Currently, the most successful treatments combine relaxation training with cognitive interventions focused on making the worry...

Anterior Plication Postanal Repair and Total Pelvic Floor Repair

Postanal repair was more popular in an era when routine EAUS was not available. Currently, it is rarely performed in the United States, but may be considered in select patients with no sphincter defect who have failed biofeedback and conservative measures or in whom an overlapping sphincter repair has achieved anatomic but not functional success. A study of this technique at our institution involved the analysis of results from 20 postanal repairs with a follow-up of 23 months.10 The success rate was 35 as indicated by a significant improvement in the inconti-

Systemic Side Effects and Complications

Another major concern with the use of corticosteroids is adrenocortical insufficiency. The adrenal gland is an endocrine (hormone-producing) gland located on top of each kidney. The adrenal cortex produces corticosteroidlike chemicals. In adrenocortical insufficiency, there is a decrease or shutdown in the body's natural production of similar substances. Due to physiologic biofeedback, when corticosteroid therapy is used, the body senses the additional drug in the system. The body then decreases natural production in order to bring levels back into balance. When natural production is diminished over time, there may be atrophy (tissue death) of the adrenal cortex. If atrophy occurs, the body can no longer make the normal quantity of chemical itself, causing problems when the therapeutic dose is discontinued.

Imagery and relaxation

There is a wide range of relaxation methods including progressive relaxation, imagery training, biofeedback, meditation, hypnosis, and autogenic training, but little evidence to indicate superiority of any one approach. Furthermore, there is little evidence to support the presumption that insomniacs are hyperaroused in physiological terms or that relaxation has its effect through autonomic change. At the cognitive level, these techniques may act through distraction and the promotion of mastery. During relaxation the mind focuses upon alternative themes such as visualized images or physiological responses. In meditation the focus is upon a 'mantra' and in self-hypnosis upon positive self-statements. Relaxation may be effective for thought processes that are anxiety-based, confused, and which flit from topic to topic.

Psychological treatments

Psychological treatments(4) are derived from different theoretical formulations of the aetiology of pain. These include behavioural, cognitive, and psychodynamic approaches that have been developed specifically for the treatment of chronic pain. Other approaches include various forms of 'stress management' including relaxation techniques, biofeedback, and hypnosis. Psychological treatments are rarely used in isolation, either from each other or from additional interventions.

Respiratory disorders Asthma

Asthma is one of the classic 'psychosomatic diseases'. Emotional arousal causes changes in airway tone. The severity of an asthma attack is highly correlated with presence of major depressive disorder, panic attacks, and level of fear. Psycho-education, relaxation, biofeedback, and family therapy have each shown efficacy in the management of asthma 31 Particularly important in the management of asthma is education about the adverse effects of antiasthma medications, which include jitteriness, palpitations, and insomnia. These side-effects may require treatment with behavioural and or psychopharmacological therapies.

Solitary Rectal Ulcer Syndrome

The mainstay of treatment of SRUS is behavioral techniques (biofeedback) directed at retraining pelvic floor coordination. In addition, the patient is taught posturing and appropriate use of abdominal musculature to minimize straining. Biofeedback also teaches patients to restrict the number of visits to the toilet, the duration of these visits, digitations, laxative use, and, most importantly, psychological support. The psychological effects are most evident in the short-term improvement of symptoms with the ability to resume normal employment despite nonhealing of the ulcer on sigmoidoscopic examination.8 Unlike surgery, it is noninvasive and free of side effects. Beneficial results deteriorate over time with only half of the patients maintaining benefits more than 36 months.9 However, repeat courses of biofeedback therapy reestablish success with behavioral modification. In one study of 13 patients followed for 57 months, Marchal et al.10 found that simple resection did not improve...

Urethral Pain Syndrome

Treatment is focused on symptomatic relief. Urethral massage can be therapeutic and aids in making the diagnosis. Removing local and dietary irritants in the same manner as with vestibulitis is necessary. Biofeedback, including functional electrical stimulation, and physical therapy may be helpful. Pain sensation can be reduced with local anesthetics, analgesics, and tricyclics. A bladder-training regimen may decrease associated frequency. On occasion, multichannel urodynamics may demonstrate urethral instability, which may typically respond to functional electrical stimulation. Urethral dilation is no longer recommended as a treatment option, but has historically yielded good results.

Anal Physiology Testing

Anal physiology testing is used at our institution to verify that the puborectalis muscle relaxes when straining occurs. Paradoxical puborectalis contraction occurs when this does not happen and is treated with biofeedback. We also use anal physiology testing to look for an anorectal inhibitory reflex. Absence of this points to Hirschsprung's disease. A small number of adults with lifelong constipation are found annually in our institution with short segment Hirschsprung's. Verification that a patient can defecate a balloon transanally placed in the rectum is also done and is performed in the anal physiology laboratory.

Degenerative Disease Of The Cervical Spine

A wide variety of alternative treatments have also been utilized for treatment of symptomatic spondylosis. Often, these treatments are invoked if preliminary conventional methods have failed or if the patient wants to avoid surgery. Acupuncture, deep muscle stimulation, chiropractic manipulation, biofeedback and other such methods remain alternatives. The rationale and results of such techniques are beyond the scope of this chapter. In the authors' experience, some patients appear to obtain some improvement of their pain symptoms from such techniques. It is unclear, however, if this represents the natural history of the disease since, again, as for steroid injections, the techniques involved do not appear to directly alter the underlying pathophysiology of the pain.

Adjunctive Treatment Methods

Various adjunctive biofeedback treatment methods have been used throughout the years. Patients with symptoms of difficult, infrequent, or incomplete micturition or evacuation often exhibit increased PFM activity while performing the Valsalva maneuver during the initial evaluation and are taught the anorectal coordination maneuver. It remains unclear which of the three components - sphincter training, sensory conditioning, or rec-toanal coordination - is most useful in the treatment for fecal incontinence. However, most agree that additional treatment methods may be helpful with symptomatic improvement depending on the underlying condition.

Sensory Discrimination Training for Fecal Incontinence

The sensory discrimination training technique involves a series of brief balloon inflations, noting the volume that induces a sensation of the urge to defecate thereby establishing a current sensory threshold. The volume is subsequently reduced by 25 and a series of insufflations are repeated until the patient is able to promptly recognize the new stimuli. Once patients learn to associate the increase in intrarectal pressure with balloon inflation, the patient is encouraged to recognize sequentially smaller volumes of distention. Thus, after each session, new sensory thresholds are established. The mechanisms by which biofeedback training improves rectal perception are unclear. It is suggested that biofeedback training may recruit sensory neurons adjacent to damaged afferent pathways. However, the speed with which sensory thresholds improve during biofeedback suggests that patients use existing afferent pathways, but learn to pay more attention to weak sensations and to recognize...

Bowel Retraining for Functional Disorders of the Colon Rectum and Anus

Bowel retraining refers to physiotherapeutic, or nonoperative, approaches to functional colorectal disorders. These nonsurgical or conservative measures may form the initial management for patients with both constipation and anal incontinence. They also provide means of effective therapy for mild forms of functional colonic disorders, high-risk surgical candidates, and for those patients who decline an operation. They may be as an adjunct to surgical therapy, or as part of a continuum once surgery has been completed. Bowel retraining involves diet manipulation, medical intervention, and biofeedback therapy.1-3 In this chapter, bowel retraining will be discussed with respect to the two major classes of functional colorectal disorders, constipation and fecal incontinence.

Bowel Retraining for Constipation

Along with dietary changes and pharmacotherapies, biofeedback is a viable option for the treatment of constipation. Biofeedback refers to therapy in which patients are trained to be more aware of and responsive to their bowels. It has been increasingly used in the management of functional pelvic floor disorders, such as constipation from obstructed defecation, fecal incontinence, and rectal pain. In patients with constipation secondary to obstructed defecation, biofeedback is used to heighten the patient's awareness of the sphincters and levator muscles to retrain these muscles to consciously relax during the act of defecation. One cause of pelvic outlet obstruction occurs as a result of nonrelaxation of the puborectalis muscles. This condition may be related to significant psychosocial stresses that may cause the patient to alter their normal defecatory patterns. Biofeedback facilitates bowel retraining through counseling and audio or visual feedback that allows the patient to...

Bowel Retraining for Anal Incontinence

Anal incontinence is the involuntary loss of control of rectal contents (solid, liquid, or gas) and can be secondary to a variety of causes. Conservative measures such as dietary manipulation, pharmacologic intervention, scheduled rectal emptying, perineal exercises, and biofeedback therapy are effective in many patients who are not surgical candidates or who do not desire surgical intervention for fecal incontinence. The bowel can then be trained to effectively reestablish continence using combinations of these techniques. Biofeedback, or operant conditioning, is an effective form of behavioral therapy for fecal incontinence. The use of biofeedback is most successful in patients with minor incontinence in whom a viable, functioning, innervated sphincter exists. Using anal EMG probes or manometry catheters, the subject is shown the results of the anal and rectal pressure changes generated during the squeeze. Exercises that contract and relax muscles of the pelvic floor are performed...

Colectomy with Ileorectal Anastomosis

A frequent dilemma is the order in which to manage patients who exhibit slow transit constipation and paradoxical puborectalis contraction. Traditionally, some surgeons thought that the paradox should be managed with biofeedback before the surgical intervention. However, many patients fall into the paradoxical muscle problem because they need to strain and bear down in any attempt to evacuate stool and gain relief. In our experience, until the need to excessively strain is eliminated, biofeedback is not as helpful, therefore, the colectomy should be performed first. If the patient still has difficulty after surgical recovery, they are reassessed with anal physiology. If paradox is found, biofeedback is then recommended.

Anorectal Dysfunction

Behavioral techniques, such as defecation training and biofeedback measures, have been successfully employed in the treatment of pelvic floor disorders, but they have not been specifically examined in PD patients. Sacral nerve stimulation is a technique that might conceivably have some application in PD patients, but has not yet been evaluated. Surgical treatment, such as colectomy, is rarely necessary in PD patients.

Overlapping Sphincter Repair

Anorectal Surgery Pictures

The incontinence score guides both the intensity of the investigation and any subsequent therapeutic decisions because its takes into account the severity, type, and degree of incontinence with consideration of its effect on lifestyle. Conservative measures, including medical intervention and biofeedback, are reserved for patients with low incontinence scores or who are poor surgical candidates. Only moderately or severely incontinent patients whose lifestyles are significantly affected should be offered surgical intervention. Physiologic evaluation is important in not only determining candidacy for these procedures, but also in assigning prognosis. The typical physiologic evaluation involves endoanal ultrasound, anal manometry, elec-tromyography, and pudendal nerve terminal motor latency (PNTML) testing. Discovery of isolated anterior sphincter defects warrants surgical correction in appropriate patients before implementation of other techniques. Initial physiologic evaluation of...

Rectoanal Intussusception

For patients with internal intussusception and constipation from obstructive or dyssynergic defecation, the first line of therapy is conservative treatment aimed at restoring normal defecatory habits. Behavioral modifications include suppressing the urge to strain, minimizing toileting time, and decreasing the number of toilet visits. Additional behavioral modifications can be accomplished with biofeedback therapy, particularly in patients with obstructed defecation related to paradoxical, or nonrelax-ing puborectalis syndrome. Dietary modifications include a fiber-enriched diet, fiber supplementation, and eight glasses of noncaffeinated beverages per day, all of which promote regularity and restoration of normal rectal motil-ity. Laxatives and scheduled enemas may also be beneficial in rectal evacuation and suppressing the urge to strain.

Session Duration and Frequency

At the onset of biofeedback therapy, it may be difficult to ascertain how many sessions are required for successful training. The number of biofeedback training sessions should be customized for each patient depending on the complexity of their functional disorder as well as the patient's ability to learn and master a new skill. They are typically scheduled from 1 to 1.5 hourly visits once or twice weekly. Additionally, periodic reinforcement is recommended to improve long-term outcome.

S Evidence statements

Two further placebo-controlled RCTs addressed the effectiveness of biofeedback and electrical stimulation of the pelvic floor muscles. The first RCT addressed biofeedback in combination with behaviour modification, pharmacological adjustment and pelvic floor training.301 The results showed no significant differences between the groups on any of the outcome measures assessed. The other RCT examined the use of electrical stimulation of the pelvic floor muscles followed by pelvic floor exercises.302 Significant beneficial effects were observed on all but one of the outcomes measures assessed.


Electromyography is the study of electrical activities generated by muscle, using either surface or needle electrodes. It provides useful information about sphincter function, but is most valuable when performed with cystometry. Although direct needle electromyography of the urethral sphincter provides the most accurate information, surface electrodes are more often used. Electromyography recording shows the activity of the voluntary component of the urinary sphincter mechanism and the overall activity of the pelvic floor. The interpretation is mainly restricted to the recording of progressively increasing EMG activity during bladder filling (guarding reflex). Reduced or silent EMG activity during bladder filling may indicate an incompetent urethral closure mechanism. Normally, EMG activity should decrease during voluntary voiding if this does not occur, urethral function may be overactive. Increased EMG activity during voiding may indicate abdominal straining. Waxing and waning of...


The opposite approach would be to assume that the cases with positive findings are accounted for by movement execution during (and despite the instruction of) motor imagery. In contrast with the visual system, which can easily be deprived of input, the situation is far more complicated for motor output. There is continuous output, and imagery easily elicits electromyographic (EMG) activity above this resting level. Voluntary relaxation, which in itself may activate M1 as discussed above, and suppression of such imagery-induced activity is difficult to achieve and usually requires training. The problem of controlling for involuntary movement during imagery has been noted by several groups. One way of ensuring pure imagery would be to perform extensive EMG monitoring. EMG has indeed been used in the context of imagery studies. In the study by Porro et al.,109 EMG recordings showed some activity increases during the imagery condition in roughly half of the subjects. However, these...


Treatment with hot baths, nonsteroidal antiinflammatory drugs, muscle relaxants, or levator muscle massage is recommended. Levator muscle massage consisting of, deep, digital pressure over the puborectalis portion of the levator floor is effective in 50-60 . EMG-based biofeedback may provide improvement in pain.

Behavioral Therapies

Behavioral therapy includes bladder drills, bladder train-ing,habit training,timed voiding,pelvic floor muscle training, and biofeedback. It is a means for the patient to regain cortical control over the detrusor muscle and bladder outlet. Bladder training incorporates timed voiding habits and bladder function,whereas pelvic floor training emphasizes control of the bladder outlet and increased sphincter resistance. Current approaches include combinations of voiding schedules, bladder diaries, fluid and diet management, and pelvic floor exercises.

Fecal Incontinence

Sacral nerve stimulation has been used for fecal incontinence. Ganio et al.8 studied 23 patients with a two-staged approach, five of whom went on to be implanted. Patients had fecal incontinence at least twice every 2 weeks for 2 months, failed biofeedback therapy, and had structurally intact external and internal anal sphincters. Sphincter dysfunction was demonstrated with fecal incontinence associated with low resting and or squeeze pressures. Seventeen patients had reduction of liquid or solid stool losses by more than 50 , and 14 were completely continent to both liquid and solid stool. In patients with urge incontinence, there was a decrease in losses per week from five to one. Manovolumetric findings showed improvements in maximum resting pressure, rectal sensitivity, first sensa

Surgical Approaches

These futile attempts have included division of the puborectalis muscle either posteriorly or laterally, anorectal myectomy, rectopexy, and progressive anal dilation. Not only were these attempts unsuccessful, but some resulted in unacceptable levels of temporary or permanent incontinence. Another dilemma the clinician may be confronted with is how to approach the constipated patient with both slow colonic transit and pelvic outlet obstruction. In short, the key to success in this population is appropriate patient selection. In fact, a significant proportion of constipated patients have NRPS.9 It is imperative to accurately identify these patients using a combination of transit studies and pelvic floor function tests, before proceeding with colectomy and ileorectal anastomosis. The use of such comprehensive preoperative investigations resulted in a 97 success rate in those patients who underwent surgical therapy.10 It is our practice to recommend biofeedback therapy before...

Habit Training

A voiding diary is the starting point for bladder training by allowing the patient to see how often voiding and incontinence actually occur. This is then used to set a voiding interval. Patients who are infrequent voiders are instructed to do timed voiding every 2 to 2-1 2 hours during waking hours. Regular bladder emptying should result in less incontinent episodes. Patients are then instructed to increase the voiding interval by 15 to 30 minutes per week in order to achieve voiding every 3 to 4 hours while awake with less urgency and less incontinence. Timed voiding has been proven effective in patients with urgency, frequency, and urge and stress incontinence. The goal of retraining is increased functional bladder capacity. The initial prescribed voiding interval may be as little as every 30 minutes in patients whose baseline diaries show voiding occurs more often than every 30 minutes. Urge suppression strategies assist with maintaining bowel and bladder control by educating...

Urinary Incontinence

Outcomes of studies that compare pelvic muscle exercises alone to pelvic muscle exercises with biofeedback emphasize the importance of appropriate PFM identification. Bergio et al.10 concluded that both groups significantly reduced the frequency of incontinence. The biofeedback group averaged a 75.9 reduction in incontinence, significantly greater than the 51 reduction shown by the verbal feedback group. Furthermore, whereas the biofeedback group improved in the strength and selective control of the PFMs, the same improvement was not seen in the verbal group. In a review of randomized clinical trials of physical therapy for stress urinary incontinence (SUI) and based on levels of evidence criteria, strong evidence was found to suggest that PFM exercises are effective in reducing the symptoms of SUI.11 They found no evidence that PFM exercises with biofeedback were more effective than PFM exercises alone. In contrast in, a meta-analysis of studies that examined the patients with SUI,...


TMJ (temporomandibular joint syndrome) can also cause a loss of bone support. Ear and jaw pain and difficulty in opening the mouth are symptoms, often a result of underlying muscle tension. Bruxism, or grinding of teeth, is usually a part of the syndrome. Calcium, 1 g, and magnesium, 350 mg, taken twice daily can relax muscles. Acupuncture, biofeedback, imagery, and craniosacral osteopathy are therapies that can bring relief.


Association for Applied Psychophysiology and Biofeedback, 10200 West 44th Avenue, Suite 304, Wheat Ridge, Colorado 80033, 303-4228436 Center for Applied Psychophysiology, Menninger Clinic, P.O. Box 829, Topeka, Kansas 66601, 913-273-7500 ext. 5375 Tools for Exploration, 4460 Redwood Highway, Suite 2, San Rafael, California 94903, 415-499-9050.


At Cleveland Clinic Florida, patients with constipation and a first or second degree sigmoidocele are approached with conservative measures or biofeedback therapy with the expectation of success in approximately 50 . Third degree sigmoidoceles are usually managed by sigmoid resection with a successful outcome achieved in the majority. This procedure is ideally suited to the laparoscopic approach with the expectation of shorter hospital stay and less disability. Coexisting intussusception can be treated with rectopexy at the time of surgery. If nonrelaxing pub-orectalis syndrome is coexistent, this entity should be addressed preoperatively with biofeedback therapy.