Musculoskeletal Applications

Clinical Efficacy

Meehan and Shaffer (2023) rated EMG biofeedback as efficacious and specific for treating ED. Two independent RCTs, one for participants after RP (Prota et al., 2012) and one for non-iatrogenic ED (Dorey et al., 2004, 2005), demonstrated that interventions that combine pelvic-floor muscle exercises, EMG biofeedback, and electrical stimulation could restore or improve erectile function. These RCTs found that the investigational treatment was statistically superior to alternative bona fide treatments (pelvic floor contraction exercises and lifestyle counseling). The studies were conducted in independent research settings.

FECAL ELIMINATION DISORDERS

Fecal incontinence is the involuntary release of feces or gas due to loss of anal sphincter control.



Listen to a mini-lecture on Fecal Elimination Disorders © BioSource Software LLC.


The diverse causes of fecal incontinence include congenital abnormalities that damage the spinal cord, and anal sphincter damage due to vaginal delivery, surgery, inflammatory conditions, cancer, and inflammatory bowel conditions. Medical conditions, including diabetes mellitus, stroke, spinal cord trauma, and neurodegenerative disorders, may also contribute to incontinence (Ranganath, 2012). Graphic © SciePro/Shutterstock.com.

Demographics

The prevalence of fecal incontinence is 2-3%. Childbirth is the most common predisposing factor to fecal incontinence because it may disrupt the internal or external anal sphincter or damage the pudendal nerve (Ranganath, 2012).

Anatomy and Physiology

When peristalsis transports fecal material from the sigmoid colon to the rectum, pressure on the rectal wall triggers a defecation reflex. The firing of sacral spine parasympathetic motor neurons shortens the rectum, increasing pressure on fecal material.

Increased pressure within the rectum opens the involuntary internal sphincter, voluntary diaphragm and abdominal muscle contraction, and parasympathetic stimulation. Intentional relaxation of the voluntary external sphincter expels feces, while constriction postpones defecation (Seymour, 2002). Graphic © Designua/Shutterstock.com. defecation (Seymour, 2002). Graphic © Designua/Shutterstock.com.

Biofeedback Protocols

Biofeedback should only be initiated following medical evaluation and conducted under medical supervision. The primary biofeedback modalities used to treat fecal incontinence are balloon manometers, electromyographs, and ultrasound. Clinicians design treatment protocols to increase rectal sensitivity, perianal muscle strength, and coordination between the internal and external anal sphincters (Norton & Cody, 2012).

The MindMedia anal EMG probe below detects muscle activity associated with the external anal sphincter.


              

Continence training teaches the patient to increase external rectal sphincter strength to prevent unwanted voiding of feces and develop proprioceptive cues so that signals from rectal wall stretch receptors will contract the external rectal sphincter to avoid leakage.

A manometry system (shown below) places one of three balloons (Schuster anorectal probe or others) in the anal canal to simulate the movement of fecal material, adjacent to the internal rectal sphincter, and adjacent to the external rectal sphincter. As the anal canal balloon is inflated, polygraph tracings show contractions of the internal and external rectal sphincters. Training is designed to teach the patient to contract the external rectal sphincter (preventing leakage of feces) when the anal canal balloon expands, activating rectal wall stretch receptors.





The transanal ultrasound system (below) allows physicians and patients to visualize the anal canal.




Adjunctive training procedures used in addition to biofeedback include bowel or habit training, dietary counseling, medication, home program including logs (regular bowel movements and incontinence episodes), and daily sphincter control exercises.

Biofeedback has been effective in children diagnosed with fecal incontinence and encopresis (constipation) and in adults with chronic fecal incontinence and incontinence due to obstetric complications and constipation. Several researchers have shown that patients maintain continence at long-term follow-up. Biofeedback does not correct incontinence caused by surgery to correct rectal prolapse.

Clinical Efficacy

Fecal Disorders in Children

Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.) did not evaluate biofeedback efficacy for fecal elimination disorders in children.

Biofeedback for fecal incontinence following anorectal surgery to correct malformations has produced clinical gains in several studies (Leung et al., 2006) despite a Cochrane Systematic Review (Brazzelli & Griffiths, 2006) that found no benefit to combining biofeedback with conventional treatment. Several studies (Iwai et al., 1997; van Ginkel et al., 2000) found improvement in constipation for 44-80% of the children studied.

Fecal Incontinence in Adults

Teo (2016) rated biofeedback for fecal incontinence in adults as level 4 - efficacious in Evidence-Based Practice in Biofeedback and Neurofeedback (3rd ed.).

Biofeedback for chronic fecal incontinence and incontinence due to childbirth and anorectal surgery has helped 60-92% of clients.

Vonthein et al. (2013) conducted a meta-analysis that showed that different biofeedback interventions produced remission rates that ranged from 20-54%. They found that continence rates doubled when biofeedback was combined with electrical stimulation. Meta-analyses by Enck et al. (2009) and Norman and Cody (2012) found that biofeedback modalities produced equivalent outcomes.

Solomon et al. (2013) conducted a randomized controlled trial of 120 patients using anal manometry, transanal ultrasound, and digital feedback during pelvic floor exercises. Seventy percent of these patients increased continence, and there were no group differences.

FUNCTIONAL CONSTIPATION

Functional constipation involves the abnormally slow movement of fecal material through the colon and difficulty in stool evacuation (Gilliland, 1997).



Listen to a mini-lecture on Functional Constipation © BioSource Software LLC.

Graphic © B-D-S Piotr Marcinski/Shutterstock.com.

Anatomy and Physiology

The slow movement of feces, called slow transit constipation, can be caused by chronic laxative abuse, inadequate dietary fiber and fluid consumption, and excessive alcohol or caffeine (Basson, 2015). Problems evacuating stools, termed dyssynergic defecation, may be produced by dysfunctional anal contraction/relaxation or insufficient effort (Bleijenberg, 1994; Gilliland, 1997). Graphic © joshya/Shutterstock.com.

Demographics

Chronic constipation affects about 15% of Americans, and about 2% report constant or frequent episodes (Basson, 2015).

Biofeedback Protocols

Clinicians have treated chronic constipation with EMG biofeedback, manometric biofeedback, and sensory training (Bassoti, 2004).

Clinical Efficacy

Teo (2016) rated biofeedback for chronic constipation as level 4 - efficacious in Evidence-Based Practice in Biofeedback and Neurofeedback (3rd ed.).

Biofeedback is superior to treatment as usual (TAU), including laxatives and patient education, but it has not been consistently better than new surgical interventions. Biofeedback appears more effective for correcting difficulty in evacuating stools than the slow movement of feces. While the strongest support is for EMG biofeedback, no single form of biofeedback is superior to the others (Woodward, Norton, & Chiarelli, 2014).

URINARY INCONTINENCE

Urinary incontinence (UI) is the involuntary loss of urine.

This problem affects approximately 13 million Americans, mainly women. Four common types of incontinence are urge incontinence, stress incontinence, mixed incontinence, and overflow incontinence.

Demographics

About 10-13 million Americans may experience UI. This disorder is twice as common in women as men. Urinary incontinence is the primary cause of nursing home admission when it overwhelms families who attempt to care for the relative at home (Vasavada, 2014).

Anatomy and Physiology

The urinary bladder is located in the pelvic cavity. The bladder wall consists of three coats. The intermediate coat is the detrusor muscle, composed of three smooth muscle layers. The movement of urine from the urinary bladder to the urethral orifice is controlled by the involuntary internal urethral sphincter (smooth muscle) and voluntary external urethral sphincter (skeletal muscle).

Micturition (urine discharge) is produced by the contraction of involuntary and voluntary muscles. The micturition center in spinal cord segments S2 and S3 coordinates these contractions. When bladder volume exceeds 200-400 ml, the micturition center triggers the micturition reflex. Graphic © Alila Medical Media/Shutterstock.com.



During the micturition reflex, the micturition center signals the detrusor muscle to contract and the internal urethral sphincter to relax. It blocks contraction of the external urethral sphincter, causing it to relax.

We learn to initiate or delay urination during early childhood by learning to control the external urethral sphincter and pelvic floor muscles (Choe, 2002; Geurrero & Sinert, 2002; O'Shaughnessy, 2002).

Biofeedback Protocols

Clinicians use three strategies to treat UI: reducing detrusor overactivity by monitoring the bladder using an inserted catheter, increasing the strength of pelvic floor muscles using SEMG sensors (vaginal or anal) or pressure sensors, and combining the previous methods while minimizing intra-abdominal pressure increases monitored by a rectal balloon (multimeasurement method).

Tries and Brubaker (1996) recommended the multimeasurement method because it reinforces "a more discriminate pelvic floor contraction" than single-channel methods. The multimeasurement method achieved superior reductions in incontinence episodes from 75.9-82% in about 5 sessions, compared with 43-61% reductions with single-channel biofeedback in an average of 11 sessions.

Biofeedback training sessions use devices like the mcompass ® Manometric Biofeedback System.

Clinical Efficacy

Women

Based on 20 RCTs, Meehan and Shaffer (2023) rated biofeedback for urinary incontinence in women as level 5 - efficacious and specific in Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.). Several demonstrated the superiority of biofeedback for urinary incontinence in women to credible treatments in at least two independent research setting.

The National Health Technology Assessment (NHTA) report by Imamura et al. (2010) of 55 trials involving 6608 women found that pelvic floor muscle training combined with biofeedback was effective. A Cochrane Review by Herderschee et al. (2011) of 24 trials involving 1583 women found that patients who received biofeedback reported higher remission rates or improvement than those who only received pelvic-floor muscle training (PMFT). These findings may have been biased by more extensive contact with health professionals.

Men

Based on 21 RCTs, Meehan and Shaffer (2023) rated biofeedback for urinary incontinence in men as level 5 - efficacious and specific in Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.). Most studies involved men who underwent prostatectomy (removal of the prostate).They reviewed 21 RCTs. Several demonstrated the superiority of biofeedback for urinary incontinence in men to credible treatments in at least two independent research setting.

Children

Based on 5 RCTs, Meehan and Shaffer (2023) rated biofeedback for urinary incontinence in children as level 4 - efficacious in Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.). Limited RCTs, including dysfunctional voiding (which can be independent of UI), and methodological inconsistency, precluded a higher rating.

MENISCECTOMY

After removing meniscus cartilage in the knee, a post meniscectomy patient experiences weakness in the muscles that act on the leg.



Listen to a mini-lecture on Meniscectomy © BioSource Software LLC.

A knee joint is shown below with cartilage and tendons. Graphic © joshya/ Shutterstock.com.



 

Demographics

Acute meniscal tears are diagnosed in 61 of 100,000 persons in the United States. Males outnumber females 2.5 to 1. Meniscal injury shows the highest incidence in males 31-40 and females 11-20. The rate of this problem is 60% in patients above the age of 65 (Baker, 2014).

Biofeedback Protocols

SEMG electrodes may be placed over the quadriceps femoris to assist in practicing isometric or isotonic contractions to increase muscle strength. Due to weak muscle output, the initial electrode spacing should be wide and narrowed to reduce crosstalk from co-contracting hamstring muscles. The Mind Media EXG sensor below can detect two channels of SEMG activity.



The Thought Technology Ltd. MyOnyx system combines two EMG channels with electrical stimulation.



The vastus lateralis and vastus medialis, which are trained following meniscectomy, are shown below. The graphic © design36/Shutterstock.com.


Total knee arthroplasty (TKA) treats knee pain, deformity, and instability due to degeneration or inflammation by replacing the knee with a prosthesis. Pain due to severe arthritis is the primary indication for this procedure. Physical therapy is initiated soon after surgery and involves exercises that may complement a continuous passive motion (CPM) device. Patients must usually achieve 90-degree knee flexion before discharge (Palmer & Cross, 2004). Graphic © Tridsanu Thopet/ Shutterstock.com.

Demographics

In 2009, total knee replacement surgeries exceeded 600,000, double the previous decade's number. In 2012, 4.5 million Americans lived with a total knee replacement of at least one knee. The frequency exceeded 5% for women and about 4% for men over 50 (ABC News, 2012).

Biofeedback Studies

Click on the Read More button to see research study summaries.

Clinical Efficacy

Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.) did not evaluate this application.

MUSCLE-TENDON TRANSFER

Muscle-tendon transfer is a procedure that repositions a tendon so that an attached muscle can be reoriented and produce a new movement. This operation is used when there is permanent muscle injury or paralysis and is designed to replace or reconstruct a missing motor function (Baumeister, 2013).



Listen to a mini-lecture on Muscle-Tendon Transfer © BioSource Software LLC.

Biofeedback Protocols

SEMG biofeedback increases motor unit recruitment in re-educated muscles and reduces interference from antagonist muscles. Where SEMG measurements do not correspond to a change in position, as when the recording surface (wrist) is too small for electrodes or the muscle lies too deeply, positional feedback may be superior. For example, a Thought Technology Ltd. electrogoniometer (shown below) places a potentiometer over two bones that form a joint and displays 180 degrees of joint angle changes as changes in voltage.

A Biometrics Ltd. dual-axis electrogoniometer (shown below) aids in the analysis of a joint's range of motion.

Clinical Efficacy

Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.) did not evaluate this application.

Glossary

anal EMG probe: an internal EMG electrode, which consists of two active electrodes inserted in the rectum and an external reference electrode to measure and train pelvic floor muscles (PFM).

blepharospasm: spasms of the eyelids characterized by bilateral blinking that results in symptoms that range in severity from increased blinking and periodic eyelid spasm to ocular pain, facial spasms, and disabling interference with vision.

computerized biofeedback knee joint goniometer (CBG): a biofeedback instrument that provides patients and physicians with audiovisual feedback about knee joint angle. This information is crucial in retraining total knee arthroplasty (TKA) patients to achieve a normal range of motion (ROM).

defecation reflex: pressure on the rectal wall triggers the firing of sacral spine parasympathetic motor neurons that shortens the rectum, increasing pressure on fecal material and the internal anal sphincter, which involuntarily relaxes in response to parasympathetic stimulation, voluntary diaphragm, and abdominal muscle contraction, and pressure.

detrusor muscle: the intermediate coat of the urinary bladder, composed of three smooth muscle layers.

dyssynergic defecation: difficulty evacuating stools.

electrogoniometer: an electronic device that measures the range of motion (ROM) by placing a potentiometer over the two bones that form a joint and converting voltage changes into changes in joint angle.

erectile dysfunction (ED): the inability to either achieve or maintain an erection that will permit acceptable sexual performance.

external anal sphincter (sphincter ani externus): an elliptically-shaped voluntary muscle tonically contracted to close the anal canal and orifice. Relaxation of this muscle expels feces, while constriction postpones defecation.

external urethral sphincter: the voluntary ring of skeletal muscle, located at the distal aspect of the bladder in females and below the prostate in males, controls urine flow through the urethra. Relaxation of this muscle allows urination, while contraction postpones it.

fecal incontinence: the involuntary release of feces or gas due to loss of anal sphincter control.

internal anal sphincter (sphincter ani internus): the muscular ring of involuntary muscle. Relaxation of this muscle helps the external anal sphincter expel feces, while contraction postpones defecation.

internal urethral sphincter: an involuntary ring of smooth muscle around the urethra’s opening controlled by parasympathetic fibers. Relaxation of this muscle allows urination, while contraction postpones it.

manometry system: an anorectal probe that places one of three balloons in the anal canal to simulate the movement of fecal material. The second balloon is adjacent to the internal rectal sphincter, and the third is adjacent to the external rectal sphincter. As the anal canal balloon is inflated, the software displays the contraction of the internal and external rectal sphincters.

meniscectomy: the surgical removal of torn knee fibrocartilage.

micturition center: located in segments S2 and S3 of the sacral spinal cord, it triggers the micturition reflex following the arrival of signals from bladder wall stretch receptors.

micturition reflex: when bladder volume exceeds 200-400 milliliters, the micturition center signals the detrusor muscle to contract and the internal urethral sphincter to relax and blocks contraction of the external urethral sphincter, causing it to relax.

mixed incontinence: the involuntary loss of urine that results from stress and urge incontinence. The detrusor is overactive, and the urinary sphincters are weak.

muscle-tendon transfer: a surgical procedure that repositions a tendon so that an attached muscle can be reoriented and produce a new movement when there is permanent muscle injury or paralysis.

orbicularis oculi: the facial muscle that closes the eyelids and wrinkles the forehead. Flaccid paralysis of this muscle occurs in Bell's palsy, and spasm produces blepharospasm.

overflow incontinence: urinary incontinence due to urethral blockage.

post meniscectomy patient: an individual who has had torn knee fibrocartilage removed.

prostatectomy: the removal of the prostate.

quadriceps femoris: the great leg extensor composite muscle consists of the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. This muscle is up-trained following meniscectomy and total knee arthroplasty (TKA).

rectus femoris: a component of the quadriceps femoris located on the anterior thigh that extends the leg at the knee joint and flexes the thigh at the hip joint.

slow transit constipation: the slow movement of feces through the colon.

stress incontinence: the involuntary loss of a variable amount of urine when intra-abdominal pressure increases. The problem is the failure of the urethral sphincters to resist urinary flow that is possibly caused by excessive urethral movement due to insufficient pelvic floor support and intrinsic sphincter deficiency.

total knee arthroplasty (TKA): the replacement of the knee with a prosthesis.

urge incontinence: involuntarily emptying the entire bladder produced by detrusor muscle overactivity due to detrusor myopathy (an abnormal muscle condition), neuropathy (nerve damage), and both myopathy and neuropathy.

urinary bladder: a hollow, muscular, elastic organ located in the pelvic cavity that collects urine from the ureters and stores it for release through the urethra.

urinary incontinence: the involuntary loss of urine divided into urge incontinence, stress incontinence, and mixed incontinence.

vastus lateralis: a component of the quadriceps femoris located on the lateral thigh that extends the leg at the knee joint.

vastus medialis: a component of the quadriceps femoris located on the medial thigh that extends the leg at the knee joint.

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Assignment

Now that you have completed this module, consider the conditions where muscle activity should be decreased or increased.

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