Manual Biofeedback

( Part 1 of a 3 Part Series (

Dr. Philip Maffetone

Throughout the past 30 years of clinical practice, nothing satisfies me more than seeing a patient get better immediately. Fundamentally, all of us in health care professions want our patients to improve and to live more healthfully. But because getting positive results is too often slow and arduous, most health care professionals and patients become resigned to accept chronic problems or resort to symptomatic treatments such as pain medications, muscle relaxants, sleeping pills, surgery, etc. I consistently avoid recommending symptomatic treatments and strive to find and treat the underlying cause of problems.

Over the years, I have utilized various aspects of biofeedback in my clinical practice, including treating patients with common muscle deficits, patients with brain and spinal cord injuries, professional athletes, musicians and others. My experience includes both genders in all age groups. Most of my work relied on some form of biofeedback with the purpose to: 1) obtain relatively rapid patient responses; 2) enlist patient participation in their recovery; 3) prescribe specific home-care training; 4) increase patient independence, 5) reduce health care costs; 6) broaden treatment locations (home-care, “on-the-field” athletic care, corporate coaching, etc.); 7) prevent future injury, re-injury, disability or reduced quality of life in patients undergoing rehabilitation; and 8) prevent injury, disability and reduced quality of life in otherwise healthy individuals. While these eight goals may seem lofty, having seen them achieved often enough, I’m compelled to share this powerful treatment approach I call manual biofeedback.

Manual biofeedback, a relatively simple and effective neuromuscular therapy, expands the scope of traditional EMG-type biofeedback and other hands-on physical therapies. The full spectrum of manual biofeedback includes physical assessment and treatment of a wide range of neuromuscular dysfunction caused by brain, spinal cord and local injury. It emphasizes active patient participation throughout the rehabilitation process. In place of electrodes and mechanical sensors used in most computerized biofeedback devices, manual biofeedback integrates the practitioner’s sensory system as the primary sensor. The process is similar and in some cases, identical to traditional manual muscle testing, neurological evaluations and other procedures commonly used in clinical practice.

Neuromuscular dysfunction is typically accompanied by muscle imbalance, defined here as a combination of abnormal muscle inhibition (“weakness”) and abnormal over-facilitation (tightness). Manual biofeedback addresses muscle weakness, helping the tight muscle relax to improve muscle balance. These concepts are discussed throughout all three parts of this article.

Biofeedback is a natural mechanism built into our nervous system and has been a key feature in evolution with early humans using it instinctively for survival. For example, sensing uncomfortable temperatures humans sought ways to adapt through clothing, shelter and fire, and walking on rough surfaces led to the use of protective footwear. Today, taking our temperature with a thermometer is a common form of biofeedback. In the 1930’s, Mowrer (1938) may have been the first to develop a biofeedback instrument by inventing an alarm-based device for treatment of enuresis. The term biofeedback was coined in the 1960s by scientists who used more advanced instrumentation to train human subjects to consciously alter body function through sensory input to the brain.

The many variations of biofeedback-type therapies currently used in clinical practice are designed to help assess and treat neuromuscular dysfunction. These techniques are utilized by medical doctors, physical therapists, chiropractors, psychologists and other healthcare practitioners. In addition, various biofeedback techniques have been used for pain control, stress management, improving gut function, reducing hypertension and hypotension, and to help reduce symptoms of depression. Many patients, families and other previously untrained individuals are also taught to use simple biofeedback for personal health needs. Kegal exercises, for example, are used to help improve pelvic muscle function, and have been successful in helping those with sexual dysfunction, urinary incontinence, uterine prolapse and other conditions. Electromyographic (EMG)-type biofeedback therapies are increasingly common in clinical practice to help treat and rehabilitate patients with skeletal motor deficits. Muscle electrodes monitor the degree of muscle contraction through a computer interface, helping patients learn to increase their muscle function. While effective in the clinical setting, EMG biofeedback requires a high degree of technical skill, the acquisition of relatively expensive equipment, and limits therapy to a specialized clinic.

With an understanding of the neuromuscular physiology and the experience of using various types of computer-based biofeedback, it was clear this treatment could be done manually. Furthermore, I understood that many of my former treatment successes occurred because I had provided the necessary biofeedback that normalized neuromuscular function. Now, I consider manual biofeedback the culmination of the past three decades of my clinical experience.

Manual biofeedback can help improve poor muscle function due to brain and spinal cord injury, and local muscle problems. It can be applied to a wide range of patients, including those with common aches and pains, to those with more serious physical ailments, including special-needs children and disabled adults. In addition, manual biofeedback is especially useful as a preventive tool to help avoid neuromuscular imbalances that can potentially increase morbidity and mortality, and reduced quality of life.

The majority of people with physical ailments fall into at least one of three categories:
Local muscle dysfunction is the most common cause of muscle-related physical problems. This is often associated with some form of trauma to the muscle itself, such as the result of a fall, an overstretched (so-called “pulled”) muscle, or a twisted ankle. Micro-trauma is even more common; it’s the accumulation of minor physical stress affecting a muscle, often unnoticed while it’s happening, eventually causing a more obvious muscle imbalance. Too much sitting, repetitive motion injury and walking in poor-fitting shoes are common examples of micro-trauma causing muscle dysfunction. Local muscle problems can result in a wide range of symptoms, from minor annoying discomfort to serious or chronic pain or disability. While these problems are typically thought of as “local,” they are clearly associated with some level of brain dysfunction because of the sensory and motor relationships between muscle and brain.

Brain injury can occur at any age, even before birth. Trauma, reduced oxygen or nutrient supply, and infections can easily cause brain damage resulting in poor muscle function. Cerebral palsy, Down syndrome and stroke are specific examples of serious brain injury. Some of these injuries can cause relatively minor physical problems, such as just being uncoordinated or “clumsy.”

An incomplete spinal cord injury is often due to physical trauma such as from a serious neck or back injury, but a tumor or infection can also be a cause. A spinal cord injury can adversely affect the nerves innervating a specific muscle or muscles reducing their function. Like a brain injury, spinal cord injuries can cause a wide range of problems, from relatively minor physical ones, to very serious disabilities.

One common problem in virtually all these injuries is abnormal muscle inhibition, often called muscle “weakness.” Three common terms used to describe muscle function include weak and tight when referring to abnormal muscles, and strong, associated with normal muscles. In this context, weakness is not necessarily associated with the lack of power, but rather, muscle dysfunction due to neurological deficits. Increases in muscular power, which can also increase the size of the muscle, typically occur after muscle function is improved and the patient begins utilizing more muscle movement in everyday activity.

In addition to the terms weak and tight, various other names more accurately define muscle dysfunction:
The first is a physiological definition noted above. Weakness could be described as abnormal muscle inhibition; and tightness, abnormal over-facilitation.
A second example comes from a recent National Institutes of Health consensus meeting that defined muscle weakness in children. These include the word weakness, along with ataxia, apraxia and other names based on developmental and neurological features.
A third example rates muscle function on a scale of 0 to 5. Zero to 4 is associated with weakness, with 0 having no detectable muscle contraction and 4 associated with mild weakness. A rating of 5 is considered normal.
Tight muscles are generally referred to as hypertonic, with three specific types being spasticity, dystonia and rigidity.

In this discussion, I’ll use the terms weak and tight to refer to abnormal muscles, and strong when referring to normal muscles. Manual biofeedback addresses the full spectrum of muscle function – from muscles with no detectable activity, or zero contraction, to those muscles with normal function (where improvement are associated with increases in the number of muscle fibers stimulated).

Most importantly, when a brain, spinal cord or local muscle injury occurs, there is usually a specific pattern of weak and tight muscles that follows. The primary problem is thought to be muscle weakness. This weakness immediately causes another muscle, typically the antagonist, to become tight. The tightness is the most noticeable sign of disability and often the most symptomatic regarding pain. For example, the biceps muscle flexes the elbow, and its antagonist, the triceps, extends it; when one weakens the other typically tightens. In a patient with a stroke or other brain injury, a flexed elbow position (and often other flexors) is a common sign of disability. The temptation is to “treat” the tight flexor with medication, Botox injections, or even surgery. But the abnormally inhibited (weak) triceps may be the primary cause of the abnormally tight biceps. In most cases, there are several, or sometimes many muscles involved in this process. The use of manual biofeedback attempts to reverse this pattern, helping the weak muscle get stronger and helping the tight muscle to relax.

The pattern of muscle inhibition occurs normally when an antagonist is contracted, and we can easily feel this difference in normal muscles. While sitting, place one of your hands under your thigh, with your elbow bent. Then, pull up with your hand to contract the biceps, and maintain that contraction. With the fingers of the other hand feel the tightness in the biceps. Now feel the back of the arm, the triceps muscle, and feel how loose it is, very much like a weak muscle.

This similar but abnormal pattern occurs when an injury causes muscle imbalance. Manual biofeedback primarily addresses muscle weakness, which in turn helps relax the tight muscle or muscles. Muscle imbalance, the combination of weakness and tightness, results in a vicious cycle of poor muscle function and reduced movement that often leads to pain, disability or both.

While treatment for common local muscle imbalance has been popular for many years, until recently, it was assumed that more serious brain and spinal cord injuries could not recover well, if at all. As a result, many patients with these neurological injuries were not successfully treated and often untreated. But over the last 30 years neuroscience contributed to the increasing acceptance of what many clinicians knew for a long time; the brain and spinal cord, at any age, has potential for repair, even in cases of severe damage.

One goal of manual biofeedback is to enhance neural plasticity in patients with brain injury (including cerebral palsy, stroke and traumatic brain injury), spinal cord injury, and common local muscle problems. The neurological mechanisms responsible for the clinical improvements observed with the use of these approaches are not entirely clear. Feedback activation by sensory means, including visual, auditory and proprioception with the use of biofeedback, may stimulate or recruit unused or underused synapses for motor control possibly creating new sensory engrams with resulting improvement in neuromuscular function.

Manual biofeedback can help promote continuous improvement in physical activity in those with acute and chronic problems, helping to enhance physical movement in almost anyone with muscle dysfunction. Increased movement is a powerful therapy in itself. It not only helps locomotion, posture, independence and other physical factors, but can also help improve most other areas of the body and brain, including speech, vision, balance, memory and even intellect. Modulation, the balance of excitation and inhibition, between the cerebellum and cortex from efferent and afferent transmission between muscles and brain can improve cerebellar activity. Because of the numerous cerebellar-cortical interconnections, integration of vision, communication, language and cognition are positively influenced through movement. Essentially, manual biofeedback helps the brain and body work together to increase balanced muscle activity and thus better brain function and vice versa, turning that vicious cycle of poor muscle function into a upward spiral of improved function. In addition, because muscles have other important functions, such as energy production, circulation and immune activity, increasing physical movement enhances overall health.

Manual biofeedback procedures include three important steps: assessment, treatment and movement.
Assessment helps determine which muscle or muscles require treatment;
Treatment helps the muscle contract and function better;
Movement of the muscle and related structures must be incorporated into the patient’s daily life to further improve overall function.

Manual biofeedback emphasizes active, versus passive, patient participation throughout this three-step process; often referred to as “task-oriented” versus “static” therapy. Many forms of hands-on assessment and treatment protocols may be considered static therapy – they take place with patients sitting or lying, and otherwise not enlisting certain levels of conscious neuromuscular activity, including upper motor neuron recruitment. While improving muscle function in the clinical setting is a significant first step in successful therapy, achieving this statically may incorporate less neurological activity, and may have less long-term clinical value, especially if the patient does not properly follow up with physical movement. Huang, et al. (2006) reviewed numerous studies of task-oriented versus static therapy and concluded that the effect of static-oriented biofeedback training on the patient’s daily life, such as walking, eating, reaching, etc., appears less effective than task oriented therapy. Many of these studies even concluded that little, if any, clinical effect took place, even when muscle function improved during the therapy session.

During both assessment and treatment, manual biofeedback utilizes procedures very similar or identical to standard muscle testing. Muscle testing is a commonly employed procedure first introduced in 1949 to evaluate muscle weakness in polio patients. Since then, many forms of muscle testing methods have evolved, for both evaluation and treatment. Manual biofeedback incorporates the best of these into one system.

Manual biofeedback is a relatively simple and effective neuromuscular therapy that encompasses a variety of therapies including traditional EMG-type biofeedback, various forms of physical therapy, manual muscle testing-based approaches and other hands-on remedies. When addressing primary imbalances, it can reduce the need for many other treatments. The full scope of manual biofeedback includes physical assessment of disability and treatment of a wide range of neuromuscular dysfunction caused by brain, spinal cord or local injury, and emphasizes active patient participation.

Respiratory Biofeedback
A key component of manual biofeedback

( Part 2 of a 3 Part Series (

Dr. Philip Maffetone

In this second part of my three-part article, I discuss a very important type of manual biofeedback called respiratory biofeedback, with step-by-step instructions on its use. This procedure combines two powerful therapies: The first incorporates manual biofeedback with the key breathing muscles, and the second is EEG biofeedback, or neurofeedback, which helps improve brain function and is associated with alpha wave production. As a component of manual biofeedback, respiratory biofeedback can also performed without equipment.

Everyone can benefit from respiratory biofeedback. We can use it on ourselves as a quick, effective daily remedy to reduce stress, relax and improve overall health. And, we can use it as a primary technique to treat patients. Most importantly, respiratory biofeedback is best performed before other therapies are used as it can help improve the efficacy of these remedies and often eliminate their necessity.

Respiratory biofeedback is associated with a number of significant health benefits:
It can increase oxygen to the brain, potentially improving a variety of neurological imbalances. This is accomplished through more efficient breathing that brings more air into the lungs.
It can increase the brain’s production of alpha waves. These brain waves can help reduce harmful stress hormones, especially cortisol, balance the autonomic nervous system and promote muscle relaxation – all very important features for a healthier brain and body.
Respiratory feedback can help restore and improve normal breathing. Improper breathing is often associated with brain and spinal cord injuries and is sometimes a hidden problem even in relatively healthy people.
It can help improve the function of the diaphragm and abdominal muscles. In addition to breathing, these muscles play a significant role in physical activity, improving posture and supporting the spine and pelvis.
Because of its effect on the brain and nervous system, respiratory biofeedback can help improve the function of other muscles in the body as well, and help reduce pain – two reasons to perform this procedure before other manual biofeedback.

( 2009 Philip Maffetone
Normal Breathing
Before performing respiratory biofeedback, we must first be sure the basic breathing mechanism is working properly. Without normal breathing, many muscles don’t work as well, body movement is impaired, oxygen can be reduced and many therapies, including respiratory biofeedback, may not be effective. Normal breathing is associated with proper muscle movement – the most important being the abdominal muscles and the diaphragm muscle. These muscles coordinate movements that allow us to efficiently breathe in and out. Let’s look at the two components of normal breathing – inhalation and exhalation:

During inhalation the abdominal muscles relax and extend outward, while the diaphragm muscle contracts and moves downward. This movement allows air to enter the lungs more easily and is accompanied by a slight whole-body backward extension, especially the spine.
During exhalation the abdominal muscles contract and tighten, and are gently pulled inward; the diaphragm muscle relaxes with an upward movement. This helps push air out of the lungs, with a slight whole-body flexion.

We can observe another person’s breathing and often tell if it’s correct, especially watching the belly move out on inhalation and in on exhalation. We can also evaluate our own breathing by feeling our muscles move:
Place the palm of one or two of your hands on the abdomen.
Slowly breathe in and feel the abdominal muscles expand outward. The belly should get bigger during inhalation.
Slowly exhale and feel the abdominal muscles tighten and be pulled inward. The belly is more flat on exhalation.

During normal breathing, most movement occurs in the abdominal areas with only slight movement of the chest. The chest expands more during much deeper breathing such as during exercise.

We can assess a patient by watching the abdominal movement, and also by placing our hands on his or her abdomen during breathing – we should feel the muscles expand on inhalation, and flatten and tighten on exhalation. Those who breathe improperly often move their muscles opposite that of normal. This happens for various reasons. Brain and spinal cord injuries can disturb the breathing muscles. In other individuals, poor breathing can come from stress, the stigma of not showing a big belly, and even over-exercising the abdominal muscles, making them too tight to relax.

( 2009 Philip Maffetone
If breathing is not normal, it’s important to re-train the breathing mechanism before using respiratory biofeedback. The procedure is simple – follow those steps just outlined for normal inhalation and exhalation, and continue for about two minutes, three times a day. It may only take a few days to restore the natural habit of normal breathing. Then, performing respiratory biofeedback can help maintain normal movement.

One important note: be aware of the breathing mechanism during times of stress, which is often when normal breathing can switch to abnormal breathing as we hold more tension in our abdominal and pelvic muscles.

Brain Waves
An important component of respiratory biofeedback is the production of healthy brain waves. As discussed in Part 1, neuromuscular function can be evaluated with manual muscle testing, but evaluating brain waves requires specific equipment. While working with Dr. Coralee Thompson, as she did neurofeedback, we observed that many people who were unable to produce certain healthy brain waves also had abnormal breathing patterns. When we effectively taught these patients to breathe properly, brain wave activity improved. With this in mind, I began teaching respiratory biofeedback without measuring brain waves or using EEG equipment.

Brain wave activity provides us with information on brain function. Understanding some basic information about brain waves is an important component of respiratory biofeedback.

The brain produces different frequencies and amplitudes of electrical waves depending upon levels of consciousness. Sensation, attention (self-awareness), intellectual activity and the planning of physical movement have distinct electrical correlates in the brain that can be measured. Measuring brain waves during various activities, such as reading, performing a math problem, listening to music, with eyes open and closed, provides further information about brain function. Once analyzed through brain mapping such as the quantitative EEG (QEEG), areas of the brain can be “trained” to function better through biofeedback, often referred to as neurofeedback.

Four commonly measured brain waves, and at least two others that have been observed:
beta waves (12 – 32 Hz) are associated with full awareness and high cortical activity – a busy brain, such as during a business meeting, planning a trip or mentally doing several things at one time.
alpha waves (8 – 12 Hz) are associated with a sense of “relaxed alertness” and high creativity; Typical during meditation, listening to music, and when eyes are closed. The ability to generate alpha waves is associated with the self-regulation of stress and may contribute to an expanded state of consciousness.

( 2009 Philip Maffetone
theta waves (4 – 8 Hz) are an awake but dreamy state common just before the onset of sleep; Most prevalent in youth but occurs during deep creativity and meditation in adults at any time.
delta waves (0.5 – 4 Hz) are very slow wave occurring during most stages of sleep. Abnormal if occurring while awake and may indicate a lack of nutrients such as glucose or oxygen, medication effects, or poorly functioning neurons.

Other brain waves include gamma (~30 – 80 Hz). Much less is known about this wave. It may be associated with more complex cortical function and higher levels of consciousness. A sensory motor rhythm (12 – 15 Hz) above the higher end alpha and entering beta has been associated with alert but muscle-relaxed states. Our brains should make specific waves in certain brain regions at appropriate times. An abnormality might include a normal wave occurring at the wrong time. For example, delta waves that are seen during reading or performing a simple math problem are abnormal and could account for errors. And the appearance of theta waves while in a classroom setting or driving on the highway is abnormal and could account for poor comprehension or “human error.”

The ability to produce alpha waves is associated with an overall healthy brain and body, especially in relation to controlling stress. It is one reason people have, for thousands of years, pursued meditation, the use of psychedelics and other drugs, prayer and other activities that seek to promote the alpha state. Specifically, alpha waves can reduce high levels of the stress hormone cortisol, and help balance the autonomic nervous system. These alpha waves can have dramatic effects on our whole body, such as improved memory, learning and comprehension, better blood sugar regulation, improved gut function, and balanced hormones. When we're relaxed, creative, meditating and happy, our brain produces large amounts of alpha waves. For these and other reasons, one main focus of respiratory biofeedback is the creation of alpha waves.

The inability to produce alpha waves is abnormal. Blood sugar problems, inadequate sleep, nutritional imbalance and very high levels of stress hormones can impair the ability to produce alpha waves. Even certain structural problems, such as those in the jaw joint or neck muscles innervated by the cranial nerves (neck flexors and SCM) can significantly reduce our ability to generate healthy alpha waves.

Respiratory Biofeedback Procedures
With a better understanding of brain waves and normal breathing, we’re ready to perform respiratory biofeedback. While it’s important to relax the body as much as possible during this process, if this procedure is new, you may be a little tense as you think of each step. But soon, you’ll be able relax and obtain the maximum benefits of respiratory biofeedback.

( 2009 Philip Maffetone
Here are the five steps for respiratory biofeedback:
It’s best performed relaxed, in a lying position, although slightly reclined while sitting is also effective.
Place your hands or arms on the middle of the abdomen, and keep them relaxed. This sensation and weight provides a biofeedback effect on the diaphragm and abdominal muscles during movement.
Close your eyes; this usually increases healthy alpha brain waves.
Listen to enjoyable music; also a great way to increase alpha waves, especially if headphones are used which keeps out distracting noise.
Breath easy and deep. Most people can comfortably, slowly inhale for about 5 to 7 seconds; then, exhale for the same 5 to 7 seconds. If 5 to 7 seconds makes you feel out of breath or dizzy, adjust the time – try 3 to 4 seconds during inhalation, for example, and the same for exhalation.

Continue respiratory biofeedback for about five minutes. If you have headphones, plug them in and go to  HYPERLINK "" and listen to the song Rosemary (it’s on the music player in the lower left) but any enjoyable music will work.

Caution: It’s very important to not fall asleep, or not even start drifting into sleep. If this happens, immediately discontinue the respiratory biofeedback session. Sleep produces delta brain waves – these should be avoided during respiratory biofeedback. If you start getting sleepy after 2 minutes, perform respiratory biofeedback for just less than that time and gradually work up to 5 minutes – but always avoid getting sleepy. If you consistently get sleepy during respiratory biofeedback, there may be other sleep-related issues such as sleep deprivation or sleep apnea.

Once you’ve done this procedure a few times, it will become very easy. And if you’re helping someone else perform it, make sure he or she is positioned correctly and is breathing properly.

As a therapy, respiratory biofeedback can be performed once or twice daily, or more if necessary. Many people feel invigorated afterwards, and can tell when it’s time to perform it. And again, before using manual biofeedback on other muscles, it’s best to perform respiratory biofeedback first because it can help make this and other therapies more successful.

Demonstration of
Manual Biofeedback

( Part 3 of a 3 Part Series (

Dr. Philip Maffetone

In this third and final part in my serious on manual biofeedback, I’ll discuss the “how-to” aspect of manual biofeedback. If you’re not familiar with manual muscle testing, or want to see the techniques described in this three part series, a DVD will be available soon for a better understanding of manual biofeedback. This video will includes a demonstration of most of the major skeletal muscles in the body.

Manual biofeedback is a powerful technique that can dramatically improve body function by correcting mechanical imbalances quickly. At the same time, it’s relatively easy to use. A key factor in successful manual biofeedback is experience – the more you utilize these procedures the easier and more effective it will be. In addition, the more familiar you are with muscle function, including the attachments, movement and ranges of motion, the more effective manual biofeedback will be.

Recall from the introduction that manual biofeedback is used to help weak muscles, with the 3-step process of assessment, treatment, and movement. Assessing a muscle’s ability to contract is the first step, and if it is weak, treatment can help improve its function. Both assessment and treatment involves using your hand to help the patient’s muscle contract better by resisting its movement. I’ll explain exactly how this is done below.

Body Position
The first consideration in manual biofeedback is the patient’s body position. This is the best position of the arm, leg or other body part that helps isolate the muscle, and maximizes its ability to contract. Once a muscle is in the best position we can begin manual biofeedback. For example, if we want the best position for the deltoid muscle, it’s with both the arm abducted and the elbow flexed to about 90 degrees.

Sometimes, due to extreme weakness or discomfort, you may have to hold the patient’s arm or leg in the best position. In other situations, when the muscle is significantly weak, such as the case with zero contraction, or if the muscle is very painful, it may not be possible to attain this best position. If the patient is unable to place their limb or other body part in the best position, consider it very weak. And, an alternative position for performing manual biofeedback is best used (these alternative positions are demonstrated in the video).

Here are some other important factors related to body position:
It’s important for the patient to maintain their position during manual biofeedback. If a muscle is weak, the patient’s body may attempt to move into a different position that allows other muscles to assist during contraction. This may reduce the effectiveness of manual biofeedback because the weak muscle contracts less in this situation (i.e., fewer muscle fibers are integrated into the muscle’s contraction) because other muscles are involved in the action.
At times, however, it’s not possible for the patient to obtain the best position, due to muscle tightness, excess pain or other factors. In this case, obtain a position that still allows for some amount of muscle contraction, knowing that other muscles may be participating in the movement. This will usually not preclude one from performing manual biofeedback, but the frequency may need to be increased to obtain the same results.
The best position is associated with the body movement created when the muscle contracts. For example, when the deltoid muscle contracts, the shoulder abducts to bring the arm up to a near horizontal position.
Your body position during manual biofeedback is important too. Use both hands, one to steady yourself and the patient, and the other to work on the muscle. Stand close to the patient with both feet bearing weight on the floor. When working on the deltoid muscle, for example, one of your hands stabilizes the shoulder while the other is placed on top of the elbow ready to provide an adequate force against the patient’s contracting deltoid muscle.

Direction of Movement
Once the proper body position is attained, the direction of movement is the next factor to consider. This is the direction the patient’s arm, leg or other body part will move when the muscle contracts. The direction of movement for the deltoid is further into abduction, moving the elbow in an upward direction. Your force will oppose the patient’s direction of movement.

Assessment & Treatment
Once you and the patient are in the best position, and know the direction of movement, you’re ready to begin manual biofeedback. The first step is assessment: evaluating the muscle’s ability to contract. In the case of the deltoid muscle, for example, place your hand on top of the patient’s elbow and ask him or her to push against your hand in the direction of movement. While the patient pushes upward, you apply sufficient downward force to counter the patient’s force, so that your force is opposite to the patient’s direction of the muscle’s movement. Apply enough force to keep the arm from going any higher up, but no so much force that you push the patient’s arm down. While the patient is using only one muscle, you are using several muscles to resist their contraction, and it’s often easy to over-test most individual muscles. You may need even less force to determining that a muscle is weak.

This initial assessment should result in one of three possible outcomes: 1) normal; 2) weak with minimal contraction; and 3) weak with no contraction. Let’s consider each one.
A normal contraction occurs when the patient can push against your force for 2 or 3 seconds without weakness, significant pain or muscle fatigue. In this case, there is usually no need to treat the muscle. (There are times when manual biofeedback can be used to add strength to a normal muscle.)

A muscle that is weak with minimal contraction quickly fatigues or is unable to maintain its position with the force of your hand. This weak muscle can be treated as follows:
Treatment starts in the same position as the original assessment (i.e., the best position and in the direction of movement). When the patient contracts, ask them to keep contracting – and even push harder – continuously for about 5 seconds. Strongly and continuously encourage the patient to push harder for the full 5 seconds. You provide the least amount of resistance with your hand as the patient’s muscle provides, plus slightly more to encourage a harder contraction. The goal is to get the muscle contracting at whatever level of function is has; it’s important for you not to over-power the muscle during treatment.
Repeat this 3 or 4 times in slightly different positions along the direction of movement, with a rest period between of about 5-10 seconds. For the deltoid muscle, for example, begin the first biofeedback action with the arm horizontal; then bring the arm down slightly for a second treatment; then bring the arm down further for another treatment.
You may find the muscle is much weaker in a certain position – if so, focus on this position during treatment more than the others.
Following treatment in 3 or 4 positions, assess the muscle again with the same muscle test as originally performed. The muscle should be stronger than when you started. If not, the treatment may have to be repeated. (Usually it’s obvious if the muscle is stronger and it may not have to be re-tested unless you’re not sure.)

A third possible outcome is a significantly weak muscle with no contraction. This is the case of a seriously injured muscle, such as a brain or spinal cord injury. A patient who had a stroke often has muscles that are weak with no contraction (with very tight antagonist muscles). In this case, before treating the muscle increase the brain’s awareness of it by stimulating various sensory and motor pathways, which can be done three ways:
First, use your muscle and arm movement to show the patient how the body should move when the muscle contracts. This imagery informs the brain of the necessary action.
Next, with the patient’s arm very relaxed, passively move it through its range of motion (as if the muscle was contracting). This is sometimes difficult because of accompanying muscle tightness, but any amount of movement is helpful to stimulate proprioception in the joint(s).
And third, stimulate the skin and muscle with both light and moderate massaging pressure for about 30 seconds. This increases local circulation, proprioception and the brain’s awareness of the muscle.

Following these three steps, treat the muscle as described above. In most cases of weakness with no contraction, an alternative position may be required. The deltoid muscle’s alternative position, for example, is with the elbow flexed at the side of the body since the patient may not be able to hold the arm in the best position.
With the arm in the alternative position, ask the patient to push against your hand. Keep asking the patient to push while your hand is providing slight, encouraging resistance on their arm. In difficult cases it may take several minutes before a very slight contraction is noticed, even if the arm does not noticeably move. Continue with verbal encouragement. With the least amount of contraction felt, ask the patient to push more – and more. When you feel the muscle contract, strongly encourage the patient to maintain it for about 5 seconds, then rest. Repeat this 3 or 4 times with a rest period in between.

Once you have assessed and treated a muscle, or several muscles, the third step in manual biofeedback is movement. It’s very important for the patient to use the muscle in daily activity. In the case of a severely weak deltoid muscle, for example, moving objects from a table to a shelf, combing the hair or putting on and taking off a hat utilizes this muscle. Or in very weak muscles, just contracting it may be the starting point. Most patients, once they experience contraction during the manual biofeedback session, will recall how to reproduce it.

Initially, this activity may be very minimal since the muscle contracts very little, or very little without fatigue. Be careful to not overwork the muscle, which can result in discomfort or pain. Any new movement obtained during treatment – even just contracting the muscle – should be incorporated into some activity no matter how minor the movement appears. This process increases the brain’s awareness of the muscle, helps it move better, and eventually improves the muscle’s power through repeated movement. Follow up manual biofeedback for a muscle that was weak with no contraction is usually needed. In most cases, correcting a muscle that was weak with minimal contraction requires only one effective treatment. If weakness recurs, it’s usually due to some other muscle that is more primary and must be treated.

In the case of a muscle that’s not severely weak, movement often occurs naturally throughout the day. However, it may be necessary to encourage more normal use, and emphasize to the patient the importance of movement while cautioning against over use.

Correcting a muscle or muscles around a painful joint or other area usually reduces or eliminates the pain. Continued pain often indicates the need to perform manual biofeedback on another nearby muscle. Depending on the level of pain, manual biofeedback can usually still be utilized except in cases where severe pain makes it impractical. (It’s also important to rule out other causes of pain, such as a fracture.)

Pain is often due to muscle weakness. For example, a weak muscle can cause an opposite muscle to tighten. A tight muscle is often painful. In addition, a weak muscle can allow a nearby joint to move improperly which can also cause pain and, ultimately, inflammation, causing more pain. Correcting the muscle weakness helps reduce muscle tightness, and helps the joint move more normal, reducing or eliminating pain, often quickly.

Pain may serve as an indicator that a weak muscle exists, helping you decide where to begin manual biofeedback. There is usually at least one weak muscle at or close to the area of pain, especially when there’s a painful joint. Another indication of muscle weakness may be impairment or the lack of movement, which is usually associated with one or more weak muscles. A third clue regarding where to start using manual biofeedback is muscle tightness, which are often painful to the patient and painful to the touch. In this case, the opposite muscle(s) is usually weak.

As a reminder from part 2 of this series, respiratory biofeedback often corrects muscle weakness. It’s best to have the patient perform respiratory biofeedback first, to eliminate secondary muscle imbalance; the remaining muscle problems will be less in number, and most likely be primary. Correcting primary muscle weakness can have a profound effect on the brain and nervous system, and overall body function.

TMJ Muscles
When imbalanced, the muscles of mastication – TMJ muscles – are a common cause of TMJ joint and other head and neck dysfunction. These problems are often treated with painful procedures, mouth appliances, surgery or other remedies sometimes requiring numerous treatments or long-term care. While some cases may require these approaches, more conservative remedies should be performed first in the hopes of avoiding more radical care. In short, manual biofeedback can quickly and successfully correct most TMJ muscle imbalances.

The TMJ muscles are innervated by cranial nerves and have a dramatic representation in the brain’s cortex. Both these facts are among the reasons why any relatively minor imbalance in the TMJ muscles can have significant adverse effects in the brain and body. Because the TMJ muscles can’t be manually tested like other skeletal muscles, the use of manual biofeedback for the jaw muscles employs a different assessment process.

Of all the neuromuscular areas of the human body, the TMJ muscles are the ones least understood. This is true in the areas of research and in the clinical environment. Both researchers and clinicians must rely on indirect measurements of TMJ muscles – a distinction between the jaw muscles and virtually all other skeletal muscles that are evaluated directly. Despite this, we can usually treat various types of TMJ problems successfully as most are due to muscle imbalance.

Over the past 40 years, various theories about which muscles are involved with different types of TMJ problems have evolved. The notion that TMJ muscles can be categorized as either jaw closers or jaw openers is an oversimplification. For example, the masseter and temporalis muscles are considered jaw closers while the external pterygoid a jaw opener. While it may serve to introduce these muscle actions during the learning process and is a good general starting point for treatment, there is a risk of addressing TMJ problems in a more cookbook manner. The details of TMJ muscle anatomy and physiology are quite complex and result in dramatic variations in mechanical actions.

In addition to their biomechanical complexity, the TMJ muscles have other interesting features:
There are significant biochemical relationships – for example, GABA, glutamate and other receptor sites in the TMJ area influence muscle function.
The brain is continuously modifying TMJ muscle contraction and relaxation, sometimes dramatically, during the course of simple mastication and even from one single chewing motion to the next.
TMJ muscles, unlike most other skeletal muscles, have a more localized organization of motor control.
While types of muscle fibers (for example, fast and slow twitch) are generally mixed in other muscles of the body, the TMJ muscle fibers commonly form distinct groups akin to the white and dark meat of birds.

TMJ muscles are compact, and their individual fiber attachments vary considerably. Even the normal attachments of one individual muscle can vary so much that its action may range from opening the jaw to closing it. This is due to the fanning out of many muscle fibers in a variety of directions. Consider these examples:
The lateral pterygoid muscle can have opposite actions; the lower fibers constitute a jaw opening muscle while the superior fibers close the jaw when contracted. This three-dimensional movement is one of the reasons these small TMJ muscles are so powerful.
The masseter muscle also has elaborate fanning of muscle fibers within its three different layers, making for unique rotational forces. These and other issues make isolation for the purpose of assessment and treatment virtually impossible.
The temporalis muscle is generally considered a jaw closer, but different fibers can pull on this muscle’s tendon in various directions. These include the anterior, vertical and posterior directions with some medial and lateral movements, resulting in very diverse actions.
The digastric, mylohyoid and geniohyoid muscles are also jaw openers but only if the hyoid bone is stabilized by other anterior neck muscles.

Since the TMJ muscles are not tested manually like other muscles, it’s difficult to determine which specific muscles are weak and tight. Therefore, the approach to assessing TMJ muscle imbalance is different. Instead of individual actions of specific muscles, consider the main TMJ movements – jaw opening and jaw closing. In addition, lateralization of the TMJ is sometimes important (as are other movements in the occasionally very difficult case). Any of these movements can be used to implement manual biofeedback assessment and treatment.

The assessment of TMJ muscles is first done to determine which group – jaw openers, jaw closers, etc. – is weak and requires treatment. This process begins with a good history, and a physical examination that includes palpation of the accessible muscles, and full ranges of motion of jaw opening, closing and lateralization. As in other muscle patterns, weakness is typically found in muscles opposite those that are tight. (Various other techniques for determining the types of muscle imbalance are also used by different professionals.) The most common pattern is weak jaw openers and tight jaw closers.

Once this assessment has been made, manual biofeedback is performed on the weak movement. This involves using the mandible as a lever to generally contract jaw opening or jaw closing muscles (or the muscles that lateralize the mandible). The case history below further describes this process.

SE was a college student with chronic daily headaches that began around age 12. While many potential problems were ruled out, her problems continued and she could only rely on medication to control the pain. I examined SE and found a number of neck muscles that were weak with minimal contraction, including the general neck flexors and SCM muscles, bilaterally. Respiratory biofeedback improved all these muscles but without a change in her symptoms. Upon re-evaluation, I found an imbalance in the TMJ muscles causing painful tightness of the masseter and temporalis muscles on the symptomatic side. I performed manual biofeedback on the muscles that open the jaw. In this case, we began with her jaw open only a few millimeters. I asked SE to push her chin downward against my hand; then with her mouth open slightly wider, I asked SE to push her chin against my hand; then a third time after opening slightly more; then a forth time with the mouth fully open. Within the next few minutes, as I was explaining the muscles and TMJ, SE said her headache had disappeared. In a follow up email several months later, SE stated that her headaches had not returned.

Other Manual Biofeedback Case Histories
JB had fallen through a roof during the building of a new home. Despite severe pain and various lacerations, emergency room evaluations did not reveal fractures or other more serious injury. I saw JB several weeks later. Still unable to return to work, he was unable to move his shoulder or arm without pain. Most muscle tests had to be modified due to the restriction in ranges of motion. Nine different muscles were weak with minimal contraction and pain. Respiratory biofeedback reduced this to only two weak muscles: the serratus anterior and posterior deltoid. These muscles were treated with manual biofeedback with the reduction of pain by 90% and normal muscle function. All ranges of motion improved dramatically. JB was able to return to work four days later.

WM had a stroke that disabled some muscles on his left side. Within a month he came to my office for a two-day period, during which time manual biofeedback was able to improve function of almost all his weak muscles. Because he did not live locally, I did not see WM for several months. His neurological visits revealed significant improvement in successfully contracting the previously weak muscles. However, his tibialis anterior was still weak with no contraction resulting in a “steppage” gait. WM returned to my office for a follow up visit. After several minutes of attempting to elicit contraction of the weak tibialis anterior, WM finally showed minimal muscle activity, and after several more contractions improved from a zero to a 4 (on a scale of 0 to 5). Within two weeks after returning home his neurologist evaluated him again saying the muscle was normal and the gait had normalized.

It should be noted that before the TMJ is treated, other local muscles should be evaluated which can significantly impact TMJ function. These include the upper trapezius, neck flexors (especially the SCM) and neck extensors, although any imbalance in the head and neck (and sometimes any other area) can affect TMJ function.

Part 1 of this 3-part article introduced the neuromuscular aspects of manual biofeedback. In part 2, an important part of manual biofeedback, called respiratory biofeedback, was discussed in detail. This 3rd part addressed the “how-to” aspects of manual biofeedback on skeletal muscles. It is difficult to effectively describe these procedures with just words, and I encourage the reader to also view the video demonstrations when they become available.