Got Biofeedback?
“Do you have biofeedback?” If I had a nickel for every time somebody asked me that question, I’d have a few dollars, at least.
I get why people ask it. Some have been to a doctor who tells them they need a therapist who “has” biofeedback. Others read about biofeedback on the internet. The question drives me a little nuts because biofeedback isn’t a specific thing to have. There’s no special equipment that IS biofeedback. Sometimes specialized equipment helps, and we have that equipment at Physical Therapy Your Way. But at its essence biofeedback is the process of providing conscious awareness of a normally unconscious body movement or action.
Low-Tech Biofeedback: words, touch, a mirror
Sometimes really simple tools are all that’s needed for biofeedback. Here’s an orthopedic example:
I ask someone to raise their right arm until it’s parallel to the floor. They try, but it’s not quite right. I then tell them to lift a little higher or lower until they achieve the desired position. That’s biofeedback. They weren’t aware of where their arm was in space. My verbal cueing made them aware and allowed them to correct it.
Tactile cueing is also biofeedback. To provide tactile biofeedback, I might physically adjust the person’s arm until it’s parallel to the floor or ask them to lift their arm until it touches an object I set to their shoulder height. It would also be biofeedback if I ask them to look in a mirror. They’d get visual feedback as to where their arm is, could make adjustments, and see the results of those adjustments in the mirror.
Sometimes verbal cueing, tactile cueing, or mirror training is the best biofeedback for a pelvic health patient. If we are trying to get a patient to contract her pelvic floor muscles, for example, we may cue her to use the muscles that stop the flow of urine and then provide verbal feedback on how to use them more effectively. Or for tactile biofeedback, we may insert a finger vaginally to give the patient something to squeeze her muscles around. For visual biofeedback, we may give the patient a mirror so she can see her perineum move.
Electromyographic Biofeedback
What most people are referring to when they ask if we have biofeedback is electromyography. We do, but it’s not always necessary or even helpful to use. In electromyography (EMG), an internal vaginal or rectal electrode or external electrodes over the skin measure the electrical signals nerves send to muscles. The amplitude of those electrical signals is then displayed on a monitor, providing visual feedback to the user. Some units simply show a number, others light up, and still others allow users to essentially play games by either contracting or relaxing their pelvic floor muscles.
The trouble with EMG is that the electrodes, whether internal or external, pick up electrical signals not only from the target muscles but also from those around them. Let’s say we place surface electrodes near the anus, as is often done in pelvic floor biofeedback. Those electrodes will also detect nerve signals coming from the glutes. It takes a skilled therapist to ensure the visual biofeedback that the EMG unit displays is actually reflecting the desired motion rather than a cheat or compensation.
EMG is really great for making sure muscles stay relaxed because you can’t cheat relaxation. What EMG can’t detect, though, is an electrically silent short and tight muscle. Let’s say for example your pelvic floor muscles are really short but the nerves are not actively trying to contract the muscle. EMG won’t detect that. Internal palpation will.
So, in other words, EMG biofeedback is a useful tool, but it’s not the only way to provide biofeedback, and if it’s not interpreted by a knowledgeable practitioner, the feedback it provides may be unreliable.
Real-Time Ultrasound Biofeedback
The same goes for real-time ultrasound biofeedback. If it’s not interpreted by a knowledgeable therapist, it may provide misleading information. Now don’t get me wrong, I love my ultrasound. I use it every day. It’s super cool because it allows us to see inside the body, to see what muscles are doing as they’re doing it, to see organs move as we breathe. Love, love, love.
If you don’t know what you’re doing with ultrasound, though, you might misinterpret the results.
Let’s say for example, you want to use ultrasound biofeedback to see if a patient can bulge his pelvic floor and allow it to lengthen toward his feet. You might use this motion if you have feces that’s stuck halfway out the anus and you want to give it a push so it comes all the way out. Or you might bulge the pelvic floor if you’re pushing to deliver a baby. To correctly bulge, the breathing diaphragm and abdominal muscles contract to increase pressure in the abdomen and pelvis while the pelvic floor muscles relax and passively lengthen in response to the increased pressure.
Ultrasound over the abdomen will show the net result of your bulging efforts. It’ll show if the pelvic floor is lifting up toward your head or expanding downward toward your feet. What it won’t show is if your pelvic floor muscles are helping or hindering this overall effort. It’s entirely possible for the pelvic floor to appear to bulge even though the pelvic floor muscles are contracting. The pelvic floor muscles may be doing the wrong thing, but the ab muscles are still overpowering them, so the net result looks correct even though it really isn’t.
Summary
So you can see that “having biofeedback” isn’t really enough. You don’t need a certain technology to gain awareness of your body. Instead, you need to be sure whatever method you’re using is being applied correctly. Besides, the end goal of biofeedback is to stop using it — to stop relying on external tools, to tune into your body rather than tuning into a display screen.
