Surface Electromyography
(sEMG) Biofeedback
for your Pelvic Floor
Let's find out more about this amazing tool
Surface electromyography (sEMG) biofeedback is a technique that uses electrical signals produced by muscles to provide real-time visual and auditory feedback to individuals. This information can help users become aware of their muscle activity and improve motor control or rehabilitation.
sEMG is a tool your pelvic floor therapist can use to provide you with a visual representation of how your pelvic floor muscles contract and relax.
From a broad perspective, your therapist will use the biofeedback for one, or a combination of the following:
 Uptrain - facilitate weak muscles |  Down train - inhibit tense or hypertonic muscles |
|---|---|
 Re-educate - teach muscle coordination |
Before we continue, it's important to highlight two key points:
1. Surface electromyography (sEMG) biofeedback is not a treatment
Biofeedback should be used as a learning strategy and a teaching tool; it is not a treatment on its own. Instead, it helps you understand how your pelvic floor muscles function. It should be used to enhance the therapy and cannot replace it. Please refrain from using sEMG as a device for exercising your muscles.
2. sEMG biofeedback offers an unexpected bonus:
You won't feel a thing!
You do not feel anything from the sEMG electrodes; there is no electrical buzz at all. All that happens is movement on the screen when you move.
What are some benefits of using sEMG biofeedback for your therapist?
 Objective real-time data on muscle activity |  It can be a great teaching tool helping in improvind communication |
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 It helps your therapist communicating to you what she means |
What are some benefits of using sEMG biofeedback for you?
 sEMG offers a visual representation of what your therapist is talking about |  It helps you become aware of muscles that are "hidden" |
|---|---|
 Seeing how the graph on screen correlates with what your pelvic floor muscles are doing will give you confirmation and confidence when you are doing it right |  It helps you understand the baseline strength of your pelvic floor muscles |
 It helps you understand how well you can relax your pelvic floor and can help you further relax it |  With sEMG you can compare different positions to see which ones allow for the most relaxed pelvic floor |
 With the help of sEMG and guidance from your therapist, you can learn to isolate your pelvic floor muscles from using other muscles | It can assist you in learning how to coordinate your pelvic floor muscles during activities |
 It helps you see the progress you are making |  Viewing a visual presentation of your pelvic floor muslces, may help you problem solve and enable you to formulate questions for your therapist |
 It could help you understand a missing link needed for your recovery |  Visual representations of how your muscles work can help you retain what you learned after your visit |
 A quick screenshot or a print-out copy could be handy as a keepsake or to take to your doctor's appointment |  You can discover fun facts, like how the position of your jaw and mouth can affect the tone in your pelvic floor |
 It is a great tool for anyone reporting a decrease in overall body awareness |  It gives immediate feedback of success |
Downsides of sEMG biofeedback
sEMG (surface electromyography) is a useful tool, but it is not perfect. There is no universal standard for its parameters, and your therapist should interpret the results alongside other information collected during a therapy session.
For example, it is important to note that you cannot isolate individual muscles, particularly those that are located deep within the body. Also, several environmental factors can affect the accuracy of the results.
The therapist using sEMG must receive proper training.
Limitations of surface EMG
While surface EMG is a powerful assessment tool, it has certain limitations that users must consider:
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Limited monitoring scope: It can be challenging to record multiple muscle sites simultaneously, especially for complex movements.
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Muscle substitution: Different muscles may produce similar movements, making it harder to isolate the target muscle.
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Crosstalk: Signals from nearby muscles can interfere with recordings, reducing specificity.
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Standardization issues: Variations in electrode placement between sessions or practitioners can affect data consistency.
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Interpretation limits: sEMG measures electrical activity, not muscle strength; results require proper normalization for comparison.
Understanding these constraints and applying consistent, precise measurement techniques ensures that sEMG delivers reliable and meaningful insights.
Placement of electrodes for pelvic floor sEMG biofeedback
Two of the three small round sensors are placed externally on either side of your anus, where the pelvic floor muscles are closest to the skin. A third sensor is placed nearby. (Internal electrodes are also an option when indicated.)
You can wear loose clothing over the electrodes, or your therapist can provide you with a gown. Remember, you do not feel anything through the electrodes.
Most of our clients report enjoying the visual feedback and often request to repeat the procedure during subsequent visits. Please ensure you have a detailed discussion with your therapist when planning to use sEMG.
When observing the biofeedback computer screen, what type of information can you gather?
 A baseline number when you try and relax your pelvic floor muscles as much as possible |  A visual of how quickly you can relax your pelvic after a contraction |
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 A visual of how long you can hold a pelvic floor muscle contraction | A visual of how smooth you can sustain a relaxed pelvic floor between contractions |
 Quality of fast contractions and let go (Quick flick) |  Endurance and quality of repeating contractions |
 Amplitude height, indicating strength of your pelvic floor contractions |  You can also see on the screen how another muscle group contraction, such as the abdominals compare to your pelvic floor |
 You can also observe on the screen how muscle fatigue may set in |
Ways sEMG can be utilized to increase awareness of your pelvic floor
1. Interactive mobile games
Two of the three small round sensors are placed externally on either side of your anus, where the pelvic floor muscles are closest to the skin. A third sensor is placed nearby. (Internal electrodes are also an option when indicated.)
You can wear loose clothing over the electrodes, or your therapist can provide you with a gown. Remember, you do not feel anything through the electrodes.
Most of our clients report enjoying the visual feedback and often request to repeat the procedure during subsequent visits. Please ensure you have a detailed discussion with your therapist when planning to use sEMG.
The Pelvic Floor Biofeedback Catch and Release Game
A pelvic floor muscle biofeedback game to help increase your awareness of your pelvic floor.
The Pelvic Floor Biofeedback Catch and Release Game
Deck Cards:
You will always have four cards in front of you.
Use the first two cards with every activity
The Baseline
Card
Before every new activity, determine what you baseline is, either on a scale from 0 - 10, or per the sEMG monitor.
The Quality
Check Card
Use with every activity to remind yourself to isolate your pelvic floor muscles.
"No one should see you move"
A Position
Card
1. Start with the foundation card
2. Then work with the two basic position cards
3. Then add additional position cards
A sEMG Muscle
Activity Card
Let your therapist guide you to focus on:
1. Awareness
2. Strengthening
3. Relaxation
4. Coordination
5. Or any combination of the above
Before you start the game
Before you start playing this game, it is a good idea to have your therapist do some pelvic floor awareness work with you first, so that you know where your pelvic floor is, what it feels like to contract and relax it, and what it means to isolate a pelvic floor contraction.
But if you still do not understand, then do not worry - that is why you are using the biofeedback. It is a learning tool and will help you.
How to prepare for the game
Before your therapist puts the stickers on, stand and fully relax your pelvic floor. Now estimate your baseline number for your relaxed pelvic floor. Give it a number between 0 and 10. 0 is the most fully relaxed pelvic floor you can imagine, and 10 is the most tight pelvic floor you can imagine. Remember, this is a game, so don't worry if you're not sure you are right.
Your number? For example, in this picture, the fully relaxed baseline pelvic floor number might be 7/10.
The foundation position
Before playing the game, we suggest you start in the hook-lying position (on your back with your legs bent) so your therapist can explain and show you on the computer screen how biofeedback works, what happens when you contract and relax your muscles, and how to isolate your pelvic floor.
Once you are comfortable with what biofeedback is and you have some baseline scores, you can start the game.
The rules of the Pelvic Floor Biofeedback Catch and Release Game
1. The aim of the game is to teach you awareness of your pelvic floor in a way that is fun. There is no win, lose, or fail in this game. It is not about how hard you can squeeze or how best you can relax your pelvic floor muscles.
2. Remember, you need to keep your body really still while playing this game. The biofeedback machine will register every other body movement.
3. To get the best results in the game, stay relaxed and remember to breathe normally.
4. Do not rush through any activities - you do not have to do them all. This is your time to practice the skills, so repeat each activity as many times as you want.
5. Your results will differ depending on your position, so don't compare the different positions with each other, or even to the results of a different day.
6. Make sure to use the biofeedback experience to help you try and remember what it feels like to contract and relax your pelvic floor, so that you "can carry" over to home and work what you have learnt here.
Important Note
Remember, sEMG is a tool. Let's compare sEMG to a piano and see your therapist as a piano teacher.
Just like every piano teacher, your therapist will have their own unique way of teaching and working with sEMG best. Also, they will know how to tailor the treatment to your specific needs. Not everyone should work on the same things. Some need to work on strengthening, others on relaxing their pelvic floor, and others on coordination.
Also, some institutions may have their own protocols to provide the best possible care, and these may look very different from what we describe here.
So please be flexible and do not see our game as the way it should be done.
At a minimum, we hope that reading this article may help you feel less intimidated by the overall biofeedback experience. The sEMG biofeedback can be fun, and is just a teaching tool after all.
Step 1. The Foundation Card:
In preparing for the game with your therapist, you should be done with step one. You learnt the following:
Baseline Card: First you decided the baseline number of how relaxed your pelvic floor is in standing |  Position Card: Then you assume the hook-lying position |
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 You have the electrodes in place | Baseline Card: Get another relaxed pelvic floor score in this position and other scores with the help of your therapist |
Your therapist introduces you to several of the sEMG muscle activity cards |  Quality Check Card: You learn to move your pelvic floor muscles without activating other muscle groups (No one notices what you are doing) |
Let's begin the game:
Step 2. The two Basic Position Cards:
Start with both basic position cards:
Continue to use the Baseline Card with every position you try |  Sitting on the side of the therapy table - make sure your feet are fully supported |
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 Standing, feet shoulder width apart |
After you have done the two basic position cards, you can experiment with other positions or pick those that may apply to you. Remember, you can only use positions you can hold still.
Additional position cards:
 Lying on your side to compare left and right - valuable when you have pelvic floor pain when sleeping on one side |  Compare meditation pose with sitting pose - also valuable if you have a tight pelvic floor and you are looking for a position to relax you pelvic floor muscles |
|---|---|
 Any position you can hold still in that usually cause you pain - how relaxed is your pelvic floor in this position? |  What happens with your pelvic floor when you vary the way you breath |
 Compare sitting in the toilet position using a footstool vs not using a footstool |  Compare feet pointed vs feet flat in sitting |
 Hold the position that hurts while you exercise to see what your pelvic floor is doing |  What happens with your pelvic floor when you sing high or low, or talk with a high or low voice |
What happens with your pelvic floor when you relax your jaw or make your mouth round, like saying mooo |  What happens when you stand on one leg - compare left to right |
 Try and recreate the position you sit in at work and alter the position to see what happens with your pelvic floor |  Play with ssss breathing and see what happens |
 Come up with your own position you want to investigate or are curious about |
3. sEMG Muscle Activity Cards:
What is your baseline in this position? | |
|---|---|
 Can your pelvic floor muscles contract and relax quickly on command | Can you move your pelvic floor muscles without activating other muscle groups (No one notices what you are doing) |
 Can you activate your pelvic floor muscles while breathing, walking and talking in a relaxed manner? |  Can you contract your pelvic floor appropriately and relax while performing activities or exercise? |
 Can you relax your pelvic floor while at work |  Can you relax your pelvic floor while voiding or having a bowel movement |
4. Carry-over ideas to take home:
Can your pelvic floor muscles contract and relax quickly on command | Can you move your pelvic floor muscles without activating other muscle groups (No one notices what you are doing) |
|---|---|
Can you activate your pelvic floor muscles while breathing, walking and talking in a relaxed manner? | Can you contract your pelvic floor appropriately and relax while performing activities or exercise? |
Can you relax your pelvic floor while at work | Can you relax your pelvic floor while voiding or having a bowel movement |
Indications for sEMG biofeedback
 When you urinate and defecate at the same time |  You leak when you cough or sneeze |
|---|---|
 Stress urinary incontinence |  Erectile dysfunction |
 Fecal incontinence |
Let's explore best practices for utilizing sEMG biofeedback and maximizing the benefits of each visit.
 As sEMG is applicable in various medical fields, ensure that the therapist using it is well-trained specifically in pelvic floor therapy |  Immediately after each session, practice the same exercises without the biofeedback |
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 Ensure that you apply what you have learned to practical tasks | Apply what you have learned in your exercise program and daily movements. |
 Understand the limits of sEMG as a tool |  Remember sEMG is only one part of an evaluation or treatment plan |
 Correct use of sEMG will avoid worsening of your symptoms or introduction of a new problem |  Proper use will prevent you from going in the wrong direction without realizing it. |
 Gently compare the results from one visit to another, as our bodies vary each day |  Please avoid applying lotion to the area where surface electromyography (sEMG) will be used. |
 Be mindful that sEMG units with engaging games may cause you to overwork your muscles or distract you from the intended learning objectives. |  sEMG is an amazing tool, so make sure you have fun with it! |
Alternatives to surface electromyography (sEMG) biofeedback for the pelvic floor
 A mirror |  Verbal and tactile cues from your therapist during an internal |
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 Vaginal weights | Access to a visual presentation of your pelvic floor helps you to formulate questions more |
It helps you see the progress you are making | It could help you understand a missing link needed for your recovery |
Home biofeedback devices
You have a visual representation of what your therapist is talking about | It helps you be aware of muscles that are "hidden" |
|---|---|
While doing your home exercise program, you have a visual memory of how your pelvic floor muscles work | Access to a visual presentation of your pelvic floor helps you to formulate questions more |
It helps you see the progress you are making | It could help you understand a missing link needed for your recovery |
A quick screenshot or a print-out copy could be handy as a keepsake or to take to your doctor's appointment | You can compare different positions to see which ones allows for the most relaxed pelvic floor |
It helps you understand how much you are able to relax your pelvic floor | It helps confirm the strength of your pelvic floor muscles |
It can help you figure out how to coordinate your pelvic floor muscles during activities such as coughing | You can discover fun facts, like how the position of your jaw and mouth can affect the tone in your pelvic floor |
With the help of the biofeedback and cues from your therapist, you can learn how to isolate your biceps muscle |