**1.1. Definitions**

The Association for Applied Psychophysiology and Biofeedback, Inc. (http://www.aapb.org) defines biofeedback as: "the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on those same systems, with a goal of being able to manipulate them at will." In their website it is further stated that: "Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance". Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin

temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information —often in conjunction with changes in thinking, emotions, and behavior— supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.

**•** Extrinsic urethral sphincter's deficiency.

**•** Muscle atrophy or weakness due to disuse.

**•** Specific and non-specific acute urinary retention.

**•** Female and male mixed urinary incontinence.

**•** Urinary incontinence without voiding desire.

**•** Continuous leakage and urinary frequency.

*1.1.1. Existing protocols for perineal electromyography*

Many protocols have been used to treat pelvic floor dysfunction. No single protocol is applicable to all patients given individual variations. We favour a personalized approach or "therapist guided method" in which one therapist carries out the entire treatment (Lorenzo

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Variations in described protocols include frequency and duration of the sessions. For example: Three 20-minutes sessions per week over a seven-week period (Amaro, Gameiro et al. 2006); twice weekly for 8 weeks (Voorham-van, Pelger et al. 2006); stimulator is activated on demand only by a sudden increase in intra-abdominal pressure (Nissenkorn, Shalev et al. 2004); 30 minutes per session, twice a week for 6 weeks ; 12 weeks training (Di-Gangi-Herms, Veit et al.

2006);and six weeks, two training sessions per week (Seo, Yoon et al. 2004).

*1.1.2. Scientific evidence supporting the use of biofeedback with electromyography (BFB-EMG)*

The main component of the pelvic floor musculature is the levator ani. The contraction of the levator compresses the urethra and helps continence (DeLancey 1990). The aim of pelvic floor re-education is to improve muscle function, which can significantly reduce stress incontinence. Success rates vary between 21 and 84%, but the subjective improvement is always greater than

Several studies have demonstrated the efficacy of BFB-EMG for the treatment of pelvic floor dysfunction in women with stress urinary incontinence (Burgio, C et al. 1986; Aukee, Immonen

**•** Urethral instability.

**•** Fecal incontinence.

**•** Incomplete bladder emptying.

**•** Urgency urinary incontinence..

**•** Post-micturition dribling.

Gómez, Silva Abuín et al. 2008).

the objective results.

et al. 2002).

**•** Nocturnal enuresis.

**•** Female stress urinary incontinence.

Also, biofeedback techniques have been defined as the use of instrumentation to help a person to instantly and better perceive the information of a specific physiological process which is under the control of the nervous system control but that is not correctly perceived (Miller 1974). Many physiological responses which are purely anatomical can be modified under voluntary control. The mechanisms for many of these responses include the relaxation of smooth or striated muscles or both (Repariz and Salinas 1995).

Programs for bladder re-education in women with bladder instability have opened new therapeutic perspectives for the various micturition dysfunctions (Frewen 1972 ; Cardozo, Abrams et al. 1978; Jarvis and Millar 1981; Cardozo and Stanton 1984)

Bladder sphincter re-education using surface electrodes was described for adults and children in 1979 and has since been widely applied (Maizels, King et al. 1979; Wear, Wear et al. 1979).

Electronic instrumentation allows the translation of normal or abnormal physiological processes (often unconscious) to visual or auditory signals. The method involves the manip‐ ulation of unconscious or involuntary events modifying these signals. Thus the technique is at the same time behavioural therapy and a learning process which aims at creating awareness of an unconscious function that is incorrectly performed, and to correct it. Biofeedback has allowed going from subjectivity to objectivity.

Individuals know little about their perineal region, and therefore control its functions (bladder, anorectal and sexual functions) poorly. Biofeedback permits a progressive and active aware‐ ness of these functions, creating a "ring" or "communication cycle" between patient and computer. The instructor serves as a guide in this Learning process.

Biofeedback with electromyography (BFB-EMG) was approved by the Food and Drug Administration in the USA in 1991. It has been effectively used since 1992 without secondary effects or complications (Perry 1994).

For biofeedback to be successful, it is important to have a single instructor conducting the sessions with a given patient. The following are also important for success: 1) A friendly attitude of the instructor; 2) A receptive and confident patient with sufficient cognitive ability; 3) Effective teaching technique 4) Patient's willingness to reproduce at home what was learned during the sessions; 5) A relaxed working atmosphere free of interruptions; 6) Patient friendly equipment 7) Adequate length and frequency of the sessions 8) A system of rewards to encourage the patient, 9) Confidence in success of the treatment.

The conditions listed below can benefit from biofeedback with EMG:


temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information —often in conjunction with changes in thinking, emotions, and behavior— supports desired physiological changes. Over time, these changes can endure

Also, biofeedback techniques have been defined as the use of instrumentation to help a person to instantly and better perceive the information of a specific physiological process which is under the control of the nervous system control but that is not correctly perceived (Miller 1974). Many physiological responses which are purely anatomical can be modified under voluntary control. The mechanisms for many of these responses include the relaxation of

Programs for bladder re-education in women with bladder instability have opened new therapeutic perspectives for the various micturition dysfunctions (Frewen 1972 ; Cardozo,

Bladder sphincter re-education using surface electrodes was described for adults and children in 1979 and has since been widely applied (Maizels, King et al. 1979; Wear, Wear et al. 1979). Electronic instrumentation allows the translation of normal or abnormal physiological processes (often unconscious) to visual or auditory signals. The method involves the manip‐ ulation of unconscious or involuntary events modifying these signals. Thus the technique is at the same time behavioural therapy and a learning process which aims at creating awareness of an unconscious function that is incorrectly performed, and to correct it. Biofeedback has

Individuals know little about their perineal region, and therefore control its functions (bladder, anorectal and sexual functions) poorly. Biofeedback permits a progressive and active aware‐ ness of these functions, creating a "ring" or "communication cycle" between patient and

Biofeedback with electromyography (BFB-EMG) was approved by the Food and Drug Administration in the USA in 1991. It has been effectively used since 1992 without secondary

For biofeedback to be successful, it is important to have a single instructor conducting the sessions with a given patient. The following are also important for success: 1) A friendly attitude of the instructor; 2) A receptive and confident patient with sufficient cognitive ability; 3) Effective teaching technique 4) Patient's willingness to reproduce at home what was learned during the sessions; 5) A relaxed working atmosphere free of interruptions; 6) Patient friendly equipment 7) Adequate length and frequency of the sessions 8) A system of rewards to

without continued use of an instrument.

288 Electrodiagnosis in New Frontiers of Clinical Research

allowed going from subjectivity to objectivity.

effects or complications (Perry 1994).

**•** Anal sphincter spasm.

**•** Atonic bladder.

smooth or striated muscles or both (Repariz and Salinas 1995).

Abrams et al. 1978; Jarvis and Millar 1981; Cardozo and Stanton 1984)

computer. The instructor serves as a guide in this Learning process.

encourage the patient, 9) Confidence in success of the treatment.

**•** Cauda equina syndrome with neurogenic bladder.

The conditions listed below can benefit from biofeedback with EMG:


#### *1.1.1. Existing protocols for perineal electromyography*

Many protocols have been used to treat pelvic floor dysfunction. No single protocol is applicable to all patients given individual variations. We favour a personalized approach or "therapist guided method" in which one therapist carries out the entire treatment (Lorenzo Gómez, Silva Abuín et al. 2008).

Variations in described protocols include frequency and duration of the sessions. For example: Three 20-minutes sessions per week over a seven-week period (Amaro, Gameiro et al. 2006); twice weekly for 8 weeks (Voorham-van, Pelger et al. 2006); stimulator is activated on demand only by a sudden increase in intra-abdominal pressure (Nissenkorn, Shalev et al. 2004); 30 minutes per session, twice a week for 6 weeks ; 12 weeks training (Di-Gangi-Herms, Veit et al. 2006);and six weeks, two training sessions per week (Seo, Yoon et al. 2004).

#### *1.1.2. Scientific evidence supporting the use of biofeedback with electromyography (BFB-EMG)*

The main component of the pelvic floor musculature is the levator ani. The contraction of the levator compresses the urethra and helps continence (DeLancey 1990). The aim of pelvic floor re-education is to improve muscle function, which can significantly reduce stress incontinence. Success rates vary between 21 and 84%, but the subjective improvement is always greater than the objective results.

Several studies have demonstrated the efficacy of BFB-EMG for the treatment of pelvic floor dysfunction in women with stress urinary incontinence (Burgio, C et al. 1986; Aukee, Immonen et al. 2002).

In the elderly, pelvic exercises with biofeedback in the office is more effective than pelvic floor exercises alone (Burns, Pranikoff et al. 1990).

1 diabetes and UTIs can develop renal damage with time. This is more likely in the presence of proteinuria and peripheral neuropathy. Risk factors for renal damage in women with type 2 diabetes mellitus and recurrent UTIs include old age, proteinuria and low body mass index (Geerlings, Stolk et al. 2000 ). In addition, autonomic neuropathy may cause bladder dysfunc‐

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In the presence of risk factors, bacterial strains of low virulence can cause UTIs. These risk

Prevention of recurrent UTIs should avoid the use antibiotics given the alarming rise in antibiotic resistance observed worldwide (Fihn 2003; Grabe, Bjerklund-Johansen et al. 2011).Antibiotic prophylaxis should only be used after counselling and behaviour modifica‐ tion has been attempted (Grabe, Bjerklund-Johansen et al. 2011). Other measures to prevent recurrences include immune active prophylaxis (Lorenzo-Gómez, MF et al. 2013), probiotics

Over the years much of the focus for chronic pelvic pain has been on peripheral-end-organ mechanisms, such as inflammatory or infective conditions (Engeler, Baranowski et al. 2012).

A peripheral stimulus such as infection may initiate the beginning of chronic pelvic pain, and the illness may become self-perpetuating as a result of modulation of the central nervous

Chronic pelvic pain mechanisms may involve on-going acute pain mechanisms, such as those associated with inflammation or infection, which may involve somatic or visceral tissues (Linley, Rose et al.). Nevertheless in most cases, inflammation or infection is not present (van de Merwe, Nordling et al. 2008). However, conditions that produce recurrent trauma, infection or inflammation may result in chronic pelvic pain in a small proportion of cases (van de Merwe,

Central sensitisation is responsible for a decrease in threshold and increase in response duration and magnitude of dorsal horn neurons. For instance, with central sensitisation, stimuli that are normally below the threshold may result in a sensation of fullness and a need to void (Nazif, Teichman et al. 2007) and other non-painful stimuli may be interpreted as pain and noxious stimuli may be magnified with an increased perception of pain. Also, somatic

The increased perception of stimuli in the viscera is known as visceral hyperalgesia, and the underlying mechanisms are thought to be responsible, among, others for bladder pain

Chronic bladder pain may be associated with the presence of Hunner's ulcers and glomeru‐ lation on cystoscopy, whereas other bladder pain conditions may have normal cystoscopic findings. Recent reports about prevalence of bladder pain syndrome show higher figures than

system, independent of the original cause (Engeler, Baranowski et al. 2012).

Nordling et al. 2008). Therefore such factors should be ruled out early.

tissue hyperaesthesia is associated with recurrent bladder infection.

earlier ones, ranging from 0.06% to 30% (Parsons and Tatsis 2004).

syndrome and dysmenorrhoea.

factors predispose to recurrence but do not affect outcome.

*1.2.2. Non-infectious chronic cystitis — Painful bladder syndrome*

tion(Korzeniowski 1991).

and cranberry juice.

The first study using rehabilitation assisted with pelvic floor muscles EMG for the treatment of vulvovaginal pain was published in 1995 by Glazer et al. These authors reported a cure rate greater than 50% with an average subjective improvement of 83%. Only changes in the electromyographic signal at rest preceded improvement of pain. These findings confirmed that the efficacy of the treatment depended on muscle stabilization (Glazer, Rodke et al. 1995).
