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The Truth about Biofeedback and E-Stim

Posted May 30 2012 2:09pm

Many PTs use either biofeedback or e-stim as part of their protocol for treating pelvic pain. Indeed, a google search of either term will bring up a slew of pelvic floor PT websites boasting the benefits of both treatments. Meanwhile, based on feedback we’ve received from our patients and the PTs taking our class, I believe there’s a good deal of confusion surrounding these two treatment methods, and that some PTs are misusing them.

It seems that biofeedback, e-stim or both are in some instances being used as part of cookie-cutter treatment plans with little thought given to whether they’re appropriate. The major concern with this is that in certain circumstances, misusing biofeedback and or e-stim may not only be ineffective, it can actually cause a patient’s condition to worsen.

So what’s the deal with biofeedback and e-stim? When are they appropriate for pelvic floor PT and when are they not?

In this post, I will answer those questions, and hopefully clear up the confusion surrounding these treatment methods once and for all. Let’s begin with biofeedback.


First a look at how biofeedback works: When administering biofeedback, a probe is inserted either vaginally or rectally or electrodes are stuck to the perineum and or peri-anal areas of the patient. The probe or electrodes are used to measure the electrical activity of pelvic floor muscles at rest and when contracted.

The feedback for the muscle activity is shown to a patient  in a variety of ways depending on the machine used. The patient might view them as graphs on a computer screen or as a light that lights up indicating muscle activity.

Whatever the means of giving the patient feedback, the idea is to show them their pelvic floor muscles activity. The thinking behind this is that patients can see for themselves when their muscles are too weak or too tight, and from there, using the visual feedback as a guide, they can work to either relax or contract them. In other words, biofeedback has the capacity to either assist a patient with muscle strengthening or to help a patient learn how to relax their pelvic floor.

Now that you know what biofeedback is and how it works, let’s get to how and where it fits into pelvic floor PT.

There are two appropriate uses for biofeedback in pelvic floor PT. One, is to “up train” or strengthen the pelvic floor if it’s truly weak or overstretched. The patient who might need biofeedback for this purpose likely has either incontinence or organ prolapse, not pain.

The other reason to use biofeedback is to help someone who has a tight pelvic floor learn how to relax their pelvic floor muscles. This person might have pain. With these patients, a PT would insert the sensor and instruct the patients on how to drop or relax their pelvic floor. Because they are getting visual feedback on their muscle activity, the patients can see for themselves when they are dropping their muscles. This visual feedback allows them to mentally note what it feels like when their muscles are dropped or relaxed or when they are too tight. The hope is that going forward the patients will be able to identify these feelings on their own without the sensor, and can relax their muscles when they are too tight.

While it’s okay to use the relaxation component of biofeedback on pelvic pain patients, it is not appropriate to use the strengthening/uptraining component on them. Here’s why: typically, if there is pelvic pain there are tight muscles and trigger points. Administering muscle strengthening/uptraining biofeedback under these circumstances will cause pelvic floor muscles that are already overly tight to further tighten thus causing further pain. Also, trigger points can be activated when tight or hypertonic muscles are made to tighten further. So in effect, the strengthening/uptraining biofeedback administered to the pelvic pain patient will simply serve to keep their cycle of pain spinning. Using biofeedback this way is tantamount to doing kegels if you have tight muscles and trigger points–a big no no!

All that said, while there are appropriate reasons to use biofeedback in pelvic floor PT, neither Steph nor I opt to use it. We believe our time is better spent with our patients with our hands on them. In the time it takes to hook someone up to a machine and have them go through the exercises, we could be administering manual therapy that is much more beneficial. To be sure, there are a variety of manual techniques that can cue muscles to either contract or relax. Plus, when it comes to relaxing tight muscles, we teach patients to get into a position called “the drop position.” See an illustration of the drop position below.


Now let’s get to the bottom of e-stim. As with biofeedback, e-stim, short for electrical stimulation, is administered with a probe that’s placed either in the vagina or the rectum. The probe contains sensors that deliver a weak electrical current designed to contract the muscles of the pelvic floor. The thinking is that this facilitates a pelvic floor muscle contraction.

When is e-stim not appropriate?  E-stim is not appropriate for pelvic pain PT, ever.. The reason is the same as the reason it’s not appropriate to administer strengthening/uptraining biofeedback to pelvic pain patients. But, it’s worth repeating, so here goes: the last thing you want to do is cause already too-tight, hypertonic muscles to tighten further and or irritate trigger points.

When is e-stim appropriate?

E-stim is appropriate when there’s pelvic floor weakness, for example, often with incontinence or prolapse. In these situations,  PTs can use it  to try to retrain the muscles to contract and strengthen.

To sum up, check out the crib notes I’ve provided below:


  • appropriate: uptrain/strengthen weak muscles
  • appropriate: to help relax tight or hypertonic muscles
  • not appropriate: uptrain/stengthen tight, hypertonic muscles or muscles with trigger points



  • appropriate: uptrain/strengthen weak muscles
  • not appropriate: uptrain/strengthen tight, hypertonic muscles or muscles with trigger points

I fully expect there to be pushback as a result of this post. In the class we teach for PTs, and when we lecture, we constantly come across PTs who defend both uptraining/ strengthening biofeedback and e-stim for use with pelvic pain patients who have tight or hypertonic pelvic floor muscles. Their argument is always that muscle contraction or kegels will cause what is known as “reflexive relaxation” after the contraction/kegel. The theory is that after the round of contractions/kegels, the muscles tire and thus relax.

This line of thinking is incorrect, however.

While reflexive relaxation can occur with other muscles in the body—triceps or biceps for instance–it will not happen with pelvic floor muscles. The reason is that pelvic floor muscles are different from the other muscles in the body in that they are NEVER at a fully relaxed state. That’s because they have to hold up organs and keep us continent or able to control urination or defecation. Therefore, the theory that if you tighten the muscles, they will tire and relax, doesn’t fly with the pelvic floor. If this were the case every time you tensed your pelvic floor, like with orgasm or even just when it’s cold outside, you’d be in danger of becoming incontinent.

PTs who misuse biofeedback and or e-stim are more often than not just doing what they were taught to do. Often we’ll ask the PTs who take our class if these methods work for them, and that is enough to get them to think critically about their use.

I hope this post has cleared up any confusion you might have had about biofeedback and or e-stim. But, please ask any questions you may have in the comment box or email me at .

Also, I’m really interested to know what your experiences have been with biofeedback and or e-stim?

Please let us know in the comment section. If you’d like to leave an anonymous comment, just do not fill in your name or email address, and the comment will show up as “anonymous.”

Be well,

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