CHAPTER 8. BIOFEEDBACK - WILLIAM E.

PRENTICE
OBJECTIVES
Following completion of this chapter, the student therapist will be able to:
Define biofeedback and identify its uses in a clinical setting.
Contrast the various types of biofeedback instruments.
Explain physiologically how the electrical activity generated by a muscle contraction can
be measured using an electromyograph (EMG).
Break down how the electrical activity picked up by the electrodes is amplified, processed,
and converted to meaningful information by the
biofeedback unit.
Differentiate between visual and auditory feedback.
Outline the equipment setup and clinical applications for biofeedback.
Electromyographic biofeedback is a modality that seems to be gaining increased popularity
in clinical settings. It is a therapeutic procedure that uses electronic or electromechanical
instruments to accurately measure, process, and feed back reinforcing information via
auditory or visual signals.26 In clinical practice, it is used to help the patient develop greater
voluntary control in terms of either neuromuscular relaxation or muscle reeducation
following injury.
ELECTROMYOGRAPHY AND BIOFEEDBACK
Electromyography (EMG) is a clinical technique that involves recording of the electrical
activity generated in a muscle for diagnostic purposes. It involves a sophisticated
electrodiagnostic study performed in an EMG laboratory, which uses either surface or needle
electrodes for measuring not only electrical activity in muscle but also various aspects of
nerve conduction. An electromyogram is a graphic representation of those electrical currents
associated with muscle action. Electromyography is widely used by physical therapists in the
diagnosis of a variety of neuromuscular disorders. Certainly electromyography would not be
considered a therapeutic modality.
The small portable biofeedback units that will be discussed in this chapter also measure
electrical activity in the muscle and are in fact small electromyographs. The discussion in this
chapter will be limited to the information on electromyography necessary for the therapist to
understand, to be able to effectively incorporate biofeedback techniques into clinical practice.
THE ROLE OF BIOFEEDBACK
The term "biofeedback" should be familiar because all therapists routinely serve as
instruments of biofeedback when teaching a therapeutic exercise or in coaching a movement
pattern. Using feedback can help the patient to regain function of a muscle that may have
been lost or forgotten following injury.12 Feedback includes information related to the
sensations associated with movement itself as well as information related to the result of the
action relative to some goal or objective. Feedback refers to the intrinsic information inherent
to movement, including kinesthetic, visual, cutaneous, vestibular, and auditory signals
collectively termed as response-produced feedback. However, it also refers to extrinsic

information or some knowledge of results that is presented verbally, mechanically, or

electronically to indicate the outcome of some movement performance. Therefore, feedback
is ongoing, in a temporal sense, occurring before, during, and after any motor or movement
task. Feedback from some measuring instrument that provides moment-to-moment
information about a biologic function is referred to as biofeedback.22
Perhaps the biggest advantage of biofeedback is that it provides the patient with a chance to
make appropriate small changes in performance that are immediately noted and rewarded so
that eventually larger changes or improvements in performance can be accomplished. The
goal is to train the patient to perceive these changes without the use of the measuring
instrument so that he or she can practice independently. Therefore, the patient learns early in
the rehabilitation process to do something for him- or herself and not to totally rely on the
therapist. This will help him or her to build confidence and increase feelings of self-efficacy.
Treatments using biofeedback are useful, particularly in a patient who has difficulty in
perceiving the initial small correct responses or who may have a faulty perception of what he
or she is doing. Hopefully, the rehabilitating patient will be motivated and encouraged by
seeing early signs of slight progress; thus relieving feelings of helplessness and reducing
injury-related stress to some extent.22
To process feedback information, the patient makes use of a complicated series of interrelated
feedback loops involving very complex anatomic and neurophysiologic components.35 An indepth discussion of these components is well beyond the scope of this text. Thus, our focus
will be oriented toward how biofeedback may best be incorporated in a treatment program.
BIOFEEDBACK INSTRUMENTATION
Biofeedback instruments are designed to monitor some physiologic event, objectively
quantify these monitorings, and then interpret the measurements as meaningful information.27
There are several different types of biofeedback modalities available for use in rehabilitation.
These biofeedback units cannot directly measure a physiologic event. Instead they record
some aspect that is highly correlated with the physiologic event. Thus the biofeedback
reading should be taken as a convenient indication of a physiologic process but should not be
confused with the physiologic process itself.27
Biofeedback instruments measure
Peripheral skin temperature
Finger phototransmission
Skin conductance activity
Electromyographic activity
The most commonly used instruments include those that record peripheral skin temperatures,
indicating the extent of vasoconstriction or vasodilation; finger phototransmission units
(photoplethysmograph), which also measure vasoconstriction and vasodilation; units that
record skin conductance activity, indicating sweat gland activity; and units that measure
electromyographic activity, indicating amount of electrical activity during muscle
contraction.

There are other types of biofeedback units available also, including electroencephalographs
(EEGs), pressure transducers, and electrogoniometers.
PERIPHERAL SKIN TEMPERATURE
Peripheral skin temperature is an indirect measure of the diameter of peripheral blood vessels.
As vessels dilate, more warm blood is delivered to a particular area, thus increasing the
temperature in that area. This effect is easily seen in the fingers and toes where the
surrounding tissue warms and cools rapidly. Variations in skin temperature seem to be
correlated with affective states, with a decrease occurring in response to stress or fear.
Temperature changes are usually measured in degrees Fahrenheit.27
CASE STUDY 8-1: BIOFEEDBACK
Background: A 10-year-old female subluxed her left patella while jumping rope at school.
There was immediate pain and a localized effusion which resolved with the use of an
immobilizer, intermittent ice packs, and rest over a 7-day period. Her pediatrician requested
the initiation of quadriceps rehabilitation 2 weeks later after the patient reported no pain,
minimal swelling but with a residual stiffness and sensation of weakness in the knee joint.
The physical examination was unremarkable except for limited ROM of 10-110 degrees and
the inability of the patient to successfully initiate and sustain an isometric contraction of her
quadriceps musculature.
Impression: Quadriceps inhibition secondary to injury and immobilization.
Treatment Plan: In addition to the initiation of therapeutic exercise static stretching and
active-assistive ROM exercise for the knee joint; biofeedback was initiated for the quadriceps
mechanism. Using the vastus medialis muscle as the target muscle, the skin was cleansed and
electrodes placed in alignment with the fibers of the muscle. A microvolt threshold of
detection slightly above the patient's ability to maximize auditory and visual feedback was
chosen. The patient was encouraged to perform isometric quadriceps setting exercises of 6-10
seconds duration attempting to "max out" feedback for the chosen threshold level. The
threshold was advanced and the process repeated.
Response: Over the course of the initial rehabilitation session, the patient advanced several
threshold levels and "reacquired" the ability to initiate and sustain an isometric quadriceps
muscle contraction comparable to her uninvolved extremity. She was rapidly transitioned to
limited range dynamic exercise and a functional closed-chain exercise sequence with
emphasis on terminal range knee stability. She returned to unrestricted playground activities
several weeks later.
Discussion Questions
What tissues were injured/affected?
What symptoms were present?
What phase of the injury-healing continuum did the patient presented for care in?
What are the physical agent modality's biophysical effects (direct/indirect/depth/tissue
affinity)?
What are the physical agent modality's indications/contraindications?
What are the parameters of the physical agent modality's
application/dosage/duration/frequency in this case study?

The rehabilitation professional employs physical agent modalities to create an optimum

environment for tissue healing while minimizing the symptoms associated with the trauma or
condition. What other physical agent modalities could be utilized to treat this injury or
condition? Why? How?
FINGER PHOTOTRANSMISSION
The degree of peripheral vasoconstriction can also be measured indirectly using a
photoplethysmograph. This instrument monitors the amount of light that can pass through a
finger or toe, reflect off a bone, and pass back through the soft tissue to a light sensor. As the
volume of blood in a given area increases, the amount of light detected by the sensor
decreases, thus giving some indication of blood volume. Only changes in blood volume can
be detected, because there are no standardized units of measure. These instruments are used
most often to monitor pulse.17
SKIN CONDUCTANCE ACTIVITY
Sweat gland activity can be indirectly measured by determining electrodermal activity, most
commonly referred to as the "galvanic skin response." Sweat contains salt that increases
electrical conductivity. Thus sweaty skin is more conductive than dry skin. This instrument
applies a very small electrical voltage to the skin, usually on the palmar surface of the hand or
the volar surface of the fingers where there are a lot of sweat glands, and measures the
impedance of the electrical current in micro-ohm units. Measuring skin conductance is a
technique useful in objectively assessing psychophysiologic arousal and is most often used in
"lie detector" testing.27
ELECTROMYOGRAPHIC BIOFEEDBACK
Electromyographic biofeedback is certainly the most typically used of all the biofeedback
modalities in a clinical setting. Muscle contraction results from the more or less synchronous
contraction of individual muscle fibers that compose a muscle. Individual muscle fibers are
innervated by nerves that collectively comprise a motor unit. The axon of that motor unit
conducts an action potential to the neuromuscular junction where a neurotransmitter
substance (acetylcholine) is released. As this neurotransmitter binds to receptor sites on the
sarcolemma, depolarization of that muscle fiber occurs, moving in both directions along the
muscle fiber, creating movement of ions and thus an electrochemical gradient around the
muscle fiber. Changes in potential difference or voltage associated with depolarization can be
detected by an electrode placed in close proximity (Fig. 8-1).
MOTOR UNIT RECRUITMENT
The amount of tension developed in a muscle is determined by the number of active motor
units. As more motor units are recruited and the frequency of discharge increases, muscle
tension increases.
The pattern of motor unit recruitment varies depending on the inherent properties of specific
motor neurons, the force required during the activity, and the speed of contraction. Smaller
motor units are recruited first and are somewhat limited in their ability to generate tension.
Larger motor units generate greater tension because more muscle fibers are recruited.

Motor units are recruited based on the force required in an activity and not on the type of
contraction performed. Thus the firing rate and recruitment of the motor units are dependent
on the external force required. The speed of contraction also influences motor unit
recruitment. Fast contractions tend to excite larger and depress smaller motor units.
MEASURING ELECTRICAL ACTIVITY
Despite the fact that biofeedback is used to determine muscle activity, it does not measure
muscle contraction directly. Instead it measures electrical activity associated with muscle
contraction. Movement of ions across the membrane creates a depolarization of the muscle
membranes, resulting in a reversal in polarity, followed by repolarization. The various stages
of membrane activity generate a triphasic electrical signal.4 Electrical activity of the muscle is
measured in volts, or more precisely, microvolts (1 V = 1,000,000 V).
biofeedback Measures electrical activity of muscle, not muscle contraction.
Measurement of electrical activity is made in standard quantitative units. Monitoring is useful
in detecting changes in electrical activity, although changes cannot be quantified. The
advantage of measurement over monitoring is that an objective scale is used; therefore,
comparisons can be made between different individuals, occasions, and instruments.
Measurement allows procedures to be replicated.
Unfortunately, with biofeedback units there is no universally accepted standardized
measurement scale. Each brand of biofeedback unit serves as its own reference standard.
Different brands of biofeedback equipment may give different readings for the same degree
of muscle contraction. Consequently, biofeedback readings can be compared only when the
same equipment is used for all readings.27
Treatment Tip
Biofeedback units do not directly measure muscle contraction. Instead, they measure only the
electrical activity associated with a muscle contraction. Thus the patient should understand
that the electrical activity implies some information about the quality of a muscle contraction
but does not measure the strength of that muscle contraction specifically.

Most biofeedback units use surface electrodes.

The biofeedback unit receives small amounts of electrical energy generated during muscle
contraction through an electrode. It then separates or filters this electrical energy from other
extraneous electrical activity on the skin and amplifies the electrical energy. The amplified
activity is then converted to information that has meaning to the user. Figure 8-2 is a diagram
of the various components of a biofeedback unit.
Separation and Amplification of Electromyographic Activity

Once the electrical activity is detected by the electrodes, the extraneous electrical activity, or
"noise," must be eliminated before the electrical activity is amplified and subsequently
objectified. This is accomplished by using two active electrodes and a single ground or
reference electrode in a bipolar arrangement to create three separate pathways from the
skin to the biofeedback unit (Fig. 8-3). The active electrodes should be placed in close
proximity to one another, whereas the reference electrode may be placed anywhere on the
body. Typically in biofeedback, the reference electrode is placed between the two active
electrodes.
The active electrodes pick up electrical activity from motor units firing in the muscles
beneath the electrodes. The magnitude of the small voltages detected by each active electrode
will differ with respect to the reference electrode, creating two separate signals. These two
signals are then fed to a differential amplifier that basically subtracts the signal of one active
electrode from the other. This, in effect, cancels out or rejects any components that the two
signals have in common coming from the active electrodes, thus amplifying the difference
between the signals. The differential amplifier uses the reference electrode to compare the
signals of the two active or recording electrodes (see Fig. 8-3).
There will always be some degree of extraneous electrical activity created by power lines,
motors, lights, appliances, and so on, that is picked up by the body and eventually detected by
the surface electrodes on the skin. Assuming that this extraneous "noise" is detected equally
by both active electrodes, the differential amplifier will subtract the noise detected by one
active electrode from the noise detected by the other, leaving only the true difference between
the active electrodes. The ability of the differential amplifier to eliminate the common noise
between the active electrodes is called the common mode rejection ratio (CMRR).
External noise can be reduced further by using filters that essentially make the amplifier
more sensitive to some incoming frequencies and less sensitive to others. Therefore, the
amplifier will pick up signals only at those frequencies produced by electrical activity in the
muscle within a specific frequency range or bandwidth. In general, the wider the bandwidth,
the higher the noise readings.
It must be noted that the therapist is interested in measuring the electrical activity within the
muscle. An excessive external noise that is not eliminated by the biofeedback instrument will
mask true electrical activity and will significantly decrease the reliability of the information
being generated by that device.
CONVERTING ELECTROMYOGRAPHIC ACTIVITY TO MEANINGFUL
INFORMATION
After amplification and filtering, the signal is indicative of the true electrical activity within
the muscles being monitored. This is referred to as "raw" activity. Raw activity is an
alternating voltage that means that the direction or polarity is constantly reversing (Fig. 8-4
A). The amplitude of the oscillations increases to a maximum then diminishes. Biofeedback
measures the overall increase and decrease in electrical activity. To obtain this measurement,
the deflection toward the negative pole must be flipped upward toward the positive pole;
otherwise the sum total of their deflections would cancel out one another (Fig. 8-4 B). This
process, referred to as rectification, essentially creates a pulsed direct current (DC).
Raw electrical activity may be

 Rectified
Smoothed
Integrated
Processing the Electromyographic Signal
The rectified signal can be smoothed and integrated. Smoothing the signal means eliminating
the peaks and valleys or eliminating the high-frequency fluctuations that are produced with a
changing electrical signal (Fig. 8-4 C). Once the signal has been smoothed, the signal may be
integrated by measuring the area under the curve for a specified period of time. Integration
forms the basis for quantification of EMG activity (Fig. 8-4 D).
Figure 8-1. The nerve fiber conducts an impulse to the neuromuscular
junction where acetylcholine binds to receptor sites on the sarcolemma,
inducing a depolarization of the muscle fiber that creates movement of ions
and thus an electrochemical gradient around the muscle fiber.
Figure 8-2. A. Diagram of a typical biofeedback unit. B. Biofeedback unit.
(Courtesy EMG Retraiver.)

Figure 8-3. The differential amplifier monitors the two separate signals from
the active electrodes and amplifies the difference, thus eliminating
extraneous noise.
Figure 8-4. Processing an EMG signal involves taking A. raw EMG, B.
rectifying, C. smoothing, and D. integrating it so that the information can be
presented in some meaningful format.

BIOFEEDBACK EQUIPMENT AND TREATMENT TECHNIQUES

It is imperative that the therapist have some understanding of how biofeedback units monitor
and record the electrical activity being produced in a muscle before attempting to set up and
use the biofeedback unit in the treatment of a patient. Specific treatment protocols involve
skin preparation, application of electrodes, selection of feedback or output modes, and
selection of sensitivity settings, all of which have been previously discussed. Once these are
complete, the therapist should choose to have the patient sitting, lying, or occasionally
standing in a comfortable position, depending on the treatment objectives. Generally the
therapist should begin with easy tasks and progressively make the activities more difficult.
Teaching the patient how to appropriately use the biofeedback unit and briefly explaining
what is being measured are essential. In most cases, it is recommended that the therapist
attach the biofeedback unit to him or herself and then demonstrate to the patient exactly what
will be done during the treatment.20
Indications and Contraindications for Biofeedback

Indications
Muscle reeducation
Regaining neuromuscular control
Increasing isometric and isotonic strength of a muscle
Relaxation of muscle spasm
Decreasing muscle guarding
Pain reduction
Psychologic relaxation
Contraindications
Any musculoskeletal condition in which a muscular contraction might exacerbate that
condition.
ELECTRODES
Skin-surface electrodes are most often used in biofeedback. Fine-wire indwelling electrodes
may also be used that permit localized highly accurate measurement of electrical activity.
However, these electrodes must be inserted percutaneously and thus are relatively impractical
in a clinical setting.
Various types of surface electrodes are available for use with biofeedback units. Electrodes
are most often made of stainless steel or nickel-plated brass recessed in a plastic holder.
These less expensive electrodes are effective in EMG biofeedback applications. More
expensive electrodes made of gold or silver/silver chloride also have been used.34
The size of the electrodes may range from 4 mm in diameter for recording small muscle
activity to 12.5 mm for use with larger muscle groups. Increasing the size of the electrode
will not cause an increase in the amplitude of the signal.20
Regardless of whether or not electrodes are disposable, some type of conducting gel, paste, or
cream with high salt content is necessary to establish a highly conductive connection with the
skin. Disposable electrodes come with the appropriate amount of gel and an adhesive ring
already applied so that the electrode can be easily connected to the skin. Nondisposable
electrodes need to have a double-sided adhesive ring applied. Then enough conducting gel
must be added so that it is level with the surface of the adhesive ring before the electrode is
applied to the skin.
Skin Preparation
Prior to attachment of the surface electrodes, the skin must be appropriately prepared by
removing oil and dead skin along with excessive hair from the surface to reduce skin
impedance. Scrubbing with an alcohol-soaked prep pad is recommended.34 However, if the
skin is cleaned until it becomes irritated, it may interfere with biofeedback recording.
Some surface electrodes are permanently attached to cable wires, whereas others may snap
onto the wire. Some biofeedback units include a set of three electrodes preplaced on a Velcro
band that may be easily attached to the skin.
Electrode Placement

The electrodes should be placed as near to the muscle being monitored as possible to
minimize recording extraneous electrical activity. They should be secured with the body part
in the position in which it will be monitored so that movement of the skin will not alter the
positioning of the electrodes over a particular muscle (Fig. 8-5).34
The electrodes should be parallel to the direction of the muscle fibers to ensure that a better
sample of muscle activity is monitored while reducing extraneous electrical activity.
Spacing of the electrodes is also a critical consideration. Electrodes generally detect
measurable signals from a distance equal to that of the interelectrode spacing. Therefore, as
the distance between the electrodes increases, the signal will include electrical activity not
only from muscles directly under the electrodes but also from other nearby muscles.4
DISPLAYING THE INFORMATION
At this point it is necessary to take this rectified, smoothed, and integrated signal and display
the information in a form that has some meaning. Biofeedback units generally provide either
visual or auditory feedback relative to the quantity of electrical activity. Some biofeedback
units can provide both visual and auditory feedback, depending on the output mode selected.
Visual Feedback
Raw activity is usually displayed visually on an oscilloscope. On most biofeedback units,
integrated electrical activity is visually presented, either as a line traveling across a monitor,
as a light or series of lights that go on and off, or as a bar graph that changes dimension in
response to the incoming integrated signal. Some of the newer biofeedback units have
incorporated video games as part of their visual feedback system. If a biofeedback unit uses
some type of meter, it may either be calibrated in objective units such as microvolts, or it may
simply give some relative scale of measure.34
Biofeedback information may be visual or auditory or both.
Figure 8-5. The biofeedback unit is connected via a series of electrodes to the
skin over the contracting muscle.

CASE STUDY 8-2: BIOFEEDBACK

Background: A 19-year-old male suffered a twisting injury to the right knee during football
practice. There was immediate pain, effusion, joint line tenderness, and hamstring muscle
spasm that prevented full extension of the knee. Initial treatment involved the use of an
immobilizer, intermittent application of ice packs, elevation, and rest over the first 24 hours
postinjury. Referral for rehabilitation was immediate and the patient reported to the clinic
with residual pain and minimal swelling but with residual hamstring muscle guarding that
prevented full active or passive knee extension.
Impression: Hamstring muscle spasm secondary to injury.

Treatment Plan: Therapeutic exercise, PNF contract-relax, was initiated for the knee joint
musculature primarily the hamstrings; biofeedback was also initiated for the hamstring
muscles. Using the semimembranosus/semitendinosus muscles as the targets, the skin was
cleansed and electrodes placed in alignment with the fibers of the muscles. A microvolt
threshold of detection at the level of the patient's current muscle spasm activity was chosen
with continuous auditory feedback. The patient was encouraged to isometrically contract his
hamstring muscles, then consciously think of relaxing the muscles and reducing the level of
auditory feedback. When auditory silence was achieved for the chosen microvolt level, the
threshold was reduced and the process repeated. The patient was then encouraged to actively
and passively extend the knee.
Response: Over the course of the initial rehabilitation session, the patient was able to reduce
the threshold level and "relax" the hamstring muscles to achieve full active and passive knee
extension comparable to his uninvolved extremity. He was rapidly transitioned to dynamic
exercise and a functional closed-chain exercise sequence with emphasis on terminal range
knee stability. He returned to football activities several weeks later.
Discussion Questions
What tissues were injured/affected?
What symptoms were present?
What phase of the injury-healing continuum did the patient present for care in?
What are the physical agent modality's biophysical effects (direct/indirect/depth/tissue
affinity)?
What are the physical agent modality's indications/contraindications?
What are the parameters of the physical agent modality's
application/dosage/duration/frequency in this case study?
What other physical agent modalities could be utilized to treat this injury or condition?
Why? How?
Further Discussion Questions
How would biofeedback assist in this patient's course of rehabilitation?
What would the goal of the treatment session be?
How long would you continue the use of biofeedback with this patient?
Describe how you would integrate PNF techniques with biofeedback.
The rehabilitation professional employs physical agent modalities to create an optimum
environment for tissue healing while minimizing the symptoms associated with the trauma or
condition.
Meters also may be either analog or digital. Analog meters have a continuous scale and a
needle that indicates the level of electrical activity within a particular range. Digital meters
display only a number. They are very simple and easy to read. However, the disadvantage of
a digital meter is that it is more difficult to tell where the signal falls in a given range.
Audio Feedback
On some biofeedback units, raw activity can be listened to and is one type of audio feedback.
The majority of biofeedback units have audio feedback that produces some tone, buzzing,
beeping, or clicking. An increase in the pitch of a tone, buzz, or beep, or an increase in the

frequency of clicking indicates an increase in the level of electrical activity. This would be
most useful for individuals who need to strengthen muscle contractions. Conversely,
decreases in pitch or frequency indicating a decrease in electrical activity would be most
useful in teaching patients to relax.
Setting Sensitivity
Signal sensitivity or signal gain may be set by the therapist on many biofeedback units. If a
high gain is chosen, the biofeedback unit will have a high sensitivity for the muscle activity
signal. Sensitivity may be set at 1, 10, or 100 V. A 1-V setting is sensitive enough to detect
the smallest amounts of electrical activity and thus has the highest signal gain. High
sensitivity levels should be used during relaxation training. Comparatively lower sensitivity
levels are more useful in muscle reeducation, during which the patient may produce several
hundred microvolts of EMG activity. Generally, when adjusting the sensitivity range it should
be set at the lowest level that does not elicit feedback at rest.
CLINICAL APPLICATIONS FOR BIOFEEDBACK
There are a number of clinical conditions for which biofeedback would be useful as a
therapeutic modality. The primary applications for using biofeedback include muscle
reeducation, which involves regaining neuromuscular control and increasing muscle strength;
relaxation of muscle spasm or muscle guarding; and pain reduction.
MUSCLE REEDUCATION
The goal in muscle reeducation is to provide feedback that will reestablish neuromuscular
control or promote the ability of a muscle or group of muscles to contract. It may also be used
to regain normal agonist/antagonist muscle action and for postural control retraining.
Biofeedback is used to indicate the electrical activity associated with that muscle
contraction.16
Treatment Tip
The therapist should set the signal gain on the biofeedback unit at a high-sensitivity setting
whenever the goal is relaxation, whereas a low-sensitivity setting should be used with muscle
reeducation.
When biofeedback is being used to elicit a muscle contraction, the sensitivity setting should
be chosen by having the patient perform a maximum isometric contraction of the target
muscle. Then the gain should be adjusted such that the patient will be able to achieve the
maximum on about two-thirds of the muscle contractions. If the patient cannot produce a
muscle contraction, the therapist should attempt to facilitate a contraction by stroking or
tapping the target muscle. It is also helpful to have the patient look at the muscle when trying
to contract. It may be necessary to move the active electrodes to the contralateral limb and
have the patient "practice" the muscle contraction you hope to achieve on the opposite side.
The patient should maximally contract the target muscle isometrically for 6-10 seconds.
During this contraction, the visual or auditory feedback should be at a maximum and should
be closely monitored by both the therapist and patient. Between each contraction the patient
should be instructed to completely relax the muscle such that the feedback mode returns to

baseline or zero prior to initiating another contraction. A period of 5-10 minutes working with
a single muscle or muscle group is most desirable because longer periods tend to produce
fatigue and boredom, neither of which is conducive to optimal learning.19
Treatment Tip
Biofeedback electrodes should be placed as close to the muscle as possible to minimize
"noise." They should be placed parallel to the direction of the muscle fibers. The spacing
should be close enough to monitor activity from a specific muscle. If spaced too far apart,
then electrical activity from other anatomically close muscles may also be detected.
As increases in electrical activity occur, the patient should develop the ability to rapidly
activate motor units. This can be accomplished by setting the sensitivity level to 60-80
percent of maximum isometric activity and instructing the patient to reach that level as many
times as possible during a given time period (i.e., 10 or 30 sec). Again, total relaxation must
occur between contractions.
It is essential that the treatment be functionally relevant to the patient. Attention to mobility
and muscle power cannot be neglected in favor of biofeedback therapy.19 The therapist should
have the patient perform functional movements while observing body mechanics and the
related electrical activity. Then recommendations can be made as to how movements can be
altered to elicit normal responses.8 Biofeedback is useful in patients who perform poorly on
manual muscle tests. If the patient can only elicit a fair, trace, or zero grade, then biofeedback
should be incorporated. Stronger muscles generally should be given resistive exercises rather
than biofeedback, although biofeedback has been recommended for increasing the strength of
healthy muscle.10,19
RELAXATION OF MUSCLE GUARDING
Often in a clinical setting, patients demonstrate a protective response in muscle that occurs
owing to pain or fear of movement that is most accurately described as muscle guarding.
Muscle guarding must be differentiated from those neuromuscular problems arising from
central nervous system deficits that result in a clinical condition known as muscle spasticity.
For the therapist treating patients exhibiting muscle guarding, the goal is to induce relaxation
of the muscle by reducing electrical activity through the use of biofeedback.19
Because muscle guarding most often involves fear of pain that may result when the muscle
moves, perhaps the most important goal in treatment is to modulate pain. This is best
accomplished through the use of other modalities such as ice or electrical stimulation.
Treatment Tip
With biofeedback units there is no universally accepted or standardized measurement scale.
Different machines are likely to give different readings for the same degree of muscle
contraction. Each manufacturer has its own reference standards for a particular unit. Thus,
information provided from two different units cannot be compared.

Biofeedback treatments should be designed so that the patient experiences success from the
first treatment. The patient is now attempting to reduce the visual or auditory feedback to
zero. Initially, positioning of the patient in a comfortable relaxed position is critical to
reduction of muscle guarding. A high sensitivity setting should be selected so that any
electrical activity in the muscle will be easily detected.
During relaxation training, the patient should be given verbal cues that will enhance
relaxation of either individual muscles, muscle groups, or body segments. For example, with
individual muscles or small muscle groups, the patient may be instructed to contract then
relax a specific muscle or to imagine a feeling of warmth within the muscle. For larger
muscle groups, using mental imagery or deep-breathing exercises may be useful.
As relaxation progresses, the spacing between the electrodes should be increased. Also, the
sensitivity setting should move from low to high. Both of these changes will require the
patient to relax more muscles, thus achieving greater relaxation. The patient must then apply
this newly learned relaxation technique in different positions that are potentially more
uncomfortable. Again, the goal is to eliminate muscle guarding during functional activities.19
PAIN REDUCTION
A number of therapeutic modalities discussed in this text are used for the purpose of reducing
or modulating pain. As mentioned in the section on muscle guarding, biofeedback can be
used to relax muscles that are tense secondary to fear of pain on movement. If the muscle can
be relaxed, then chances are that pain will also be reduced by breaking the "pain-guardingpain" cycle. It has been experimentally demonstrated to reduce pain in headaches and low
back pain.2,7-9,25,31 Pain modulation is often associated with techniques of imagery and
progressive relaxation.
Treating Neurologic Conditions
Biofeedback has been identified as an effective technique for treating a variety of neurologic
conditions, including hemiplegia following stroke, spinal cord injury, spasticity, cerebral
palsy, fascial paralysis, and urinary and fecal incontinence.1,3,5,6,15,18,23,28,29,32,33
SUMMARY
1. Biofeedback is a therapeutic procedure that uses electronic or electromechanical
instruments to accurately measure, process, and feed back reinforcing information by using
auditory or visual signals.
2. Perhaps the biggest advantage of biofeedback is that it provides the patient with a chance
to make correct small changes in performance that are immediately noted and rewarded so
that eventually larger changes or improvements in performance can be accomplished.
3. Several different types of biofeedback modalities are available for use in rehabilitation,
with biofeedback being the most widely used in a clinical setting.
4. A biofeedback unit measures the electrical activity produced by depolarization of a muscle
fiber as an indicator of the quality of a muscle contraction.
5. The biofeedback unit receives small amounts of electrical energy generated during muscle
contraction through active electrodes, then separates or filters extraneous electrical energy via

a differential amplifier before it is processed and subsequently converted to some type of

information that has meaning to the user.
6. Biofeedback information is displayed either visually using lights or meters or auditorily
using tones, beeps, buzzes, or clicks.
7. High sensitivity levels should be used during relaxation training, whereas comparatively
lower sensitivity levels are more useful in muscle reeducation.
8. In a clinical setting, biofeedback is most typically used for muscle reeducation, to decrease
muscle guarding, or for pain reduction.
REVIEW QUESTIONS
1. What is biofeedback and how can it be used in injury rehabilitation?
2. What are the various types of biofeedback instruments that are available to the therapist?
3. How can the electrical activity generated by a muscle contraction be measured using
biofeedback?
4. What are the important considerations for attaching biofeedback electrodes?
5. How is the electrical activity picked up by the electrodes amplified, processed, and
converted to meaningful information by the biofeedback unit?
6. What are the advantages and disadvantages of using visual and auditory feedback?
7. How should sensitivity settings be changed during relaxation training versus during muscle
reeducation?
8. What are the most common uses for biofeedback in a rehabilitation setting?
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