EMG Biofeedback – A Review of the Evidence

By |2022-11-08T12:15:23-05:00December 7th, 2021|Latest Articles|

Biofeedback is a tool that uses myoelectrical signals to help retrain muscles. It can be used to either increase or reduce muscle activity depending on the goal and diagnosis. Over the last decade, many studies have supported the use of biofeedback for musculoskeletal and neurological rehabilitation. Although research originally focused on the quadriceps and knee, evidence has since expanded to include the use of biofeedback for other orthopedic conditions and injuries. Here we take a deeper look into the evolution and expanded use of biofeedback over the last several decades.

Back in 1990-91, Draper and Ballard began investigating the effects of electromyographic biofeedback on quad function following ACL reconstruction. (1,2) They found that biofeedback was more effective in facilitating the recovery of full active knee extension than electrical stimulation alone. These findings were supported by several other studies (found here, and here, here, and here.) and even extended to other common knee conditions.

After knee surgery, quad weakness and loss of neuromuscular firing are very common, sometimes for over 6 months. (7) Several studies have addressed the benefit of biofeedback on recovery following meniscectomy. Akkaya et al. found EMG-biofeedback to be effective at reducing time on crutches, increasing quadriceps recruitment, and speeding up the rehabilitation process. (8) Kirnap et all found improvements in range of motion (ROM), overall function, and max quadricep recruitment with biofeedback. (9) After meniscus repair, biofeedback was shown to help improve muscular control, coordination, and function during activities. (10) Benefits were even seen after total knee arthroscopy in gait and quality of life when biofeedback interventions were included in rehab. (6,11,12)

The most recent addition to the knee literature has been the support of EMG biofeedback for patellar femoral pain. The use of real time visual biofeedback was shown to improve the relative contraction strength of both vastus lateralis (VL) and vastus medialis obliques (VMO), subsequently enhancing activation during daily activities. (13) In a study by Alonazi et al, after just four weeks of a biofeedback guided rehabilitation program, young males with patellar femoral pain had less pain, improved strength, and long-term function. (14)

In the last decade, evidence for biofeedback has largely expanded beyond just the knee. More recently, studies on the hip have yielded promising results for the use of EMG biofeedback after total hip arthroscopy. In 2019, Doctors Soni and Samuel demonstrated a conventional rehabilitation program with the use of biofeedback produced superior outcomes compared to a conventional rehab program alone. (15)

The main focus of biofeedback use in the ankle and foot has typically pertained to gait and stroke recovery. In this arena, it has been shown to improve strength, balance, and gait patterning. See studies here16 and here17. Additionally, a recent study by Kim and Uhm showed the effectiveness of biofeedback for improving balance and lower limb muscle in athletes with functional ankle instability. (18)

The use of biofeedback has evolved to incorporate interventions that work to reduce activation or down regulate overactive muscle groups that often cause pain and dysfunction. Additional studies published on the shoulder have supported the use of EMG biofeedback for muscle patterning and rotator cuff activation, which help address conditions such as shoulder instability, impingement, and rotator cuff repairs. For instance, Lim et al found the use of visual EMG biofeedback to be a clinically effective training tool for increasing activation and strength of the infraspinatus muscle during specific exercises while reducing the use (substitution) of the posterior deltoid. (19) Scapular dyskinesis, or poor motor patterning, is an issue with many shoulder pathologies and a focus of all scapular strengthening programs. Recently in 2020, Du et al. demonstrated that the use of visual biofeedback can help improve muscle activation and control during overhead shoulder elevation. (20) Similarly, Huang et al. showed this improved scapular muscular balance during rehab exercise was beneficial for improving symptoms associated with shoulder impingement. (21)

Another innovative area of study for biofeedback has been its use for neck pain, headaches, posture, and back pain. The main focus for intervention in these studies has been utilizing visual biofeedback to reduce activation in over active muscle groups known to cause impairment. This study by Dellve et all shows successful treatment of neck pain with use of biofeedback for down regulating the upper trap. (22) In migraines, biofeedback was shown to help decrease frequency and use of medications. (23) EMG biofeedback-assisted relaxation techniques described by Reeves helped reduce the frequency of chronic tension headaches and recent studies have built off of Jones and Wolf’s 1980 study on EMG biofeedback training for low back pain. (24, 25) They found that biofeedback during standing, trunk movements, and movement patterns yielded improved range of motion, decreased pain levels and medication intake. (25)

sEMG biofeedback is a low-risk modality, with high levels of versatility and the ability to customize treatment to achieve functional goals faster. New evidence and studies encourage the use of EMG biofeedback as an effective and innovative treatment intervention.



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