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Biofeedback in Pelvic Therapy: Making the Invisible Visible

June 2024 Darlene Ryan, PT - Fundamental Physical Therapy

Getting to Know Your Pelvic Floor

Understanding your pelvic floor is like discovering the hidden gem in your body. Picture it as a hammock of muscles supporting your pelvic organs. And to function well, it needs not only strength and endurance, but relaxation and lengthening. The normal experiences of life (childbirth, age, illness, and even stress) can throw this balance off-kilter. Restoring balance can become tricky when you don’t really know where the pelvic floor muscles are or how to make it work better. That's where pelvic physical therapy steps in, and biofeedback becomes our secret weapon.

The Role of Biofeedback: A Friendly Guide

Different Types of Biofeedback

Biofeedback is a broad category but could be defined as anything that gives us real-time information about what our bodies are doing. There are different types, each serving a unique purpose.

Visual Feedback: Viewing Position and Movement Patterns

A mirror or video camera is a very simple example of biofeedback. It can give us immediate feedback on our posture, our form as we exercise, or perfecting the ideal selfie smile.  We use mirrors a lot in PT to help patients see their spinal alignment as they are working on core strength, or their leg alignment as they work on jumping or squatting. But we can also use visual feedback for pelvic floor activity. Often individuals can’t “feel” if their pelvic floor is working, but using a mirror to see the lifting and lowering action of the pelvic muscles can help them understand what signals to send to create the best contractions.  Even more fun is the small endoscopy camera that I have that connects to a phone screen and allows the kids (and adults) to see a real time video of their muscles as they contract and relax. (Of course, they love to look in their ears and noses as well!!)

Electromyography (EMG): Monitoring Muscle Activity

EMG is like having a personal muscle detective. It uses sensors on your skin (externally or internally) to track the electrical activity in your pelvic muscles and converts it to an image that you can see on a computer screen.  The readings are high when the muscle is active and low when relaxed.  I can change the screen image to resemble a shrinking circle, a blooming flower or a launching rocket depending on the interest of the patient.  Sometimes our focus is increasing activity (building strength to reduce leakage), but other times we work to reduce activity to learn what relaxation feels like (improve stretch tolerance for pain-free function). This is so helpful for post-partum moms who may feel like they have lost connection to their pelvic floor.  But it’s also useful for the woman with pain or tension who has been holding these muscles so tight for so long that “clenched” begins to feel normal. EMG biofeedback can help either woman visualize and feel those muscles working, turning the guesswork into empowerment.

computer screen with biofeedback results
Biofeedback results for pelvic floor contraction and relaxation

Pressure Biofeedback: Assessing Pressure Changes

Pressure biofeedback uses an air-filled probe to measure the pressure changes in your pelvic region that occur when you breathe, bear down or contract the pelvic floor muscles.  I don’t use this in my clinic currently, but there are several devices that can be found that use pressure sensors and communicate with an app on your smart phone to work on pelvic floor control at home. Some even have some vibration to help you know you are doing things correctly. It's like having a tiny sherpa guiding you to the right muscles!

Incorporating Technology for Better Results

Now, you might be wondering, "Why all this technology?" “Is it really necessary?” In pelvic therapy, we like to have many different tools in our tool box of options to improve your pelvic function. Everyone responds differently to different teaching methods.  Biofeedback expands our options and is perfect to help bridge the gap of connection between the muscles and the brain.  It's about giving you a visual guide, making the invisible visible. It transforms your pelvic floor exercises from a guessing game into a personalized journey of discovery. Sometimes, it might even feel like a game to improve your score from previous sessions!  

Interoception: The Mind-Body Connection

Now that we've demystified biofeedback, let's talk about a why we use this modality in pelvic physical therapy.  In order for our bodies to function optimally, we need to know what is happening within the body and understand the signals our bodies are sending to our brains.  This involves two of our lesser-known senses – interoception and proprioception. 

Interoception is the understanding and interpretation of the signals coming from within our body and our organs (heart, stomach, bladder, etc.).  It deals with how we perceive the information that helps us to maintain homeostasis or physiologic balance.  This would involve recognizing things like hunger, nervousness, the urge to pee or poop, a racing heart, or being out of breath.   

Proprioception is the brain’s awareness of where the body is and how it is moving based on information from the muscles and joints.  It is the system that tells us where our body is in space when we can’t see it with our eyes.  This is especially important in pelvic health because we cannot naturally visually see the function of the pelvic floor muscles. Truly “out of sight, out of mind!”. It often takes some training to become really good at finding and determining how those muscles are working.  Are they clenched? Are they relaxed? Did I just do a good Kegel?  Am I still squeezing? These are questions that so many of my patients ask!

Adding real time visual feedback to what is happening is extremely helpful in reconnecting the brain’s awareness to what is happening in the body, especially for the pelvic floor.  Once the brain is able to recognize what the muscles are doing, we are able to work on specific control of the muscles to help with function.  Learning to contract the pelvic floor allows us to work on strengthening and coordination drills to support the pelvic organs and prevent leakage with daily activities and exercise.  Learning to relax the pelvic floor allows for improved bladder emptying, better gut motility, decreased pain and increased ease of penetration.

Mindfulness in Pelvic Physical Therapy

Interoception and proprioception bring mindfulness to the forefront. It's about tuning into your body's signals, understanding how stress impacts your pelvic muscles, and learning to release that tension. Sometimes pelvic pain can be caused by stress, but more often it is exacerbated by stress.  Using biofeedback to be able to see the amount of extra activity in the muscles can be helpful to understand the tension-pain connection.  Watching the changes in muscle activity as we work on relaxation techniques helps to improve understanding of how to relax the muscles and build confidence in the ability to recognize and return to this relaxed state. This can be a powerful tool for managing stress in daily life.

Personalized Treatment Plans: Recognizing Your Uniqueness

The beauty of pelvic physical therapy lies in its personalized approach. Whether you're a new mom, navigating perimenopause, or somewhere in between, your body has its own story. No two bodies are the same, and your treatment plan shouldn't be either. A personalized approach means acknowledging your uniqueness and tailoring treatments to suit your needs. As we work together, we will discover which tools and tricks work best for you to understand your body and learn to work with it to thrive!

We love having so many options to help you understand and improve pelvic function, biofeedback being one of them!

Conclusion: Celebrating Your Pelvic Health Journey

In conclusion, biofeedback is not just a technique; it's a window into your pelvic health. By understanding your pelvic floor, embracing biofeedback in whatever form works for you, and supporting the mind-body connection, we're creating personalized insight into your pelvic well-being that you can take with you for the rest of your life.

So ladies, if you're navigating the waters of pelvic health issues, know that you're not alone. Seek out a pelvic physical therapist, embark on your journey to understand your body, and celebrate every milestone along the way. Your pelvic health is worth the investment, and together, we'll ensure you know exactly what we're doing – with your well-being at the heart of it all. Cheers to pelvic health and the incredible journey ahead!


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