2022 - RS Biofeedback para El Manejo de Dme

DOI: 10.5114/areh.2022.
113241
Review article Advances in Rehabilitation, 2022, 36(1), 41–69
Efficacy of biofeedback in rehabilitation of

A – Research concept musculoskeletal disorders: A systematic review
and design
B – Collection and/or Hernán Andrés de la Barra OrtizA,C-F* , Alexandra Meza
assembly of data MatamalaA-C,E-F , Francisca López InostrozaB-F ,
C – Data analysis Catalina Lobos ArayaB-D,F , Valeria Núñez MondacaB-D,F
and interpretation
D – Writing the article Exercise and Rehabilitation Sciences Laboratory, Faculty of Rehabilitation
E – Critical revision Sciences, School of Physical Therapy, Universidad Andres Bello, Chile
of the article
F – Final approval
of article
Received: 2021-12-28 *Correspondence: Hernán Andrés de la Barra Ortiz; Exercise and Rehabilitation
Accepted: 2022-01-31 Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences,
Published: 2022-02-01 Universidad Andres Bello, Santiago 7591538, Chile; e-mail: hdelabarra@unab.cl,
handresdelabarra@yahoo.es
Abstract
Musculoskeletal disorders (MSD) are a frequent reason for consultation and the main cause of disability in population.
Electromyographic biofeedback or myofeedback (MF) is a promising treatment in rehabilitation, although studies sup-
porting its benefits in MSD have declined in recent years. The objective of this review was to describe the efficacy of MF
in function recovery, strength increase and muscle relaxation in MSD. Randomized clinical trials (RCTs) were identified
in Pubmed, Scopus, Web of Science, Cinahl and Science Direct databases dated September 2, 2021. Four independent
researchers reviewed articles titles and abstracts to determine their eligibility. Risk of bias and articles quality was asses-
sed using Rob2 tool (Cochrane) and PEDro scale. Functionality improvement, strength increase, and muscle relaxation
were considered as main outcome. Search strategy yielded 160 articles after eliminating duplicates, reducing to 26 when
selection criteria were applied. Articles were classified in strengthening (n = 16) and muscle relaxation (n = 10) according
to MF therapeutic aim. Eighteen articles were rated as low risk of bias (69.22%) and an average internal validity of 6
points was obtained. Studies showed improvements in functionality, strength increase and pain reduction with statistical
significance when MF were complemented with therapeutic exercises or other physical agents modalities (p < 0.005). MF
also showed a decrease in fear of movement, depression, and pain perception, suggesting central modulating effects. This
review supports MF efficacy in MSD rehabilitation, showing improvements in functionality and pain reduction. The re-
view allowed to establish a dosage recommendation based on articles analysis which can be considered for future RCTs.
Keywords: rehabilitation, biofeedback, musculoskeletal diseases, myofeedback,

recovery of function
Introduction depending on whether it persists for more than three

months, which occurs in 39 to 45% of patients [1,3].
Musculoskeletal pain (MSP) is currently recog- Chronic MSP is associated with sleep disturbances, fa-
nized as one of the main reasons for medical consulta- tigue, depression, and activity limitations, which affect
tion and the most common cause of disability in adults life quality and work productivity [4,5]. Currently, its
worldwide, affecting about 47% of the population [1,2]. prevalence in adults is 20%, and it is estimated that, by
MSP is classified chronologically as acute or chronic 2050, it will reach 50% [3].
This is an Open Access journal, all articles are distributed under the terms of the Creative Commons Attri-
bution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License (http://creativecommons.
org/licenses/by-nc-sa/4.0/).
42 de la Barra Ortiz HA, Matamala AM, Lopez Inostroza F, et al.
Although MSP is usually of nociceptive origin, therapeutic exercise [19–21]. Another therapeutic al-
people with chronic disorders may experience neuro- ternative is electromyographic biofeedback or myo-
pathic pain (NP) or nociplastic pain (NCP) [6,7]. NP feedback (MF), a safe and non-invasive intervention
occurs due to injury or dysfunction of the nervous sys- supported for strength increase, muscle relaxation, and
tem, manifesting clinically with hyperalgesia and al- functional recovery in a variety of MSD [22–25] be-
lodynia, muscle weakness, and impaired reflexes [8]. ing used for motor reeducation and muscle training in
NCP is characterized by altered nociception phenom- musculoskeletal, neurological, and pelvic floor condi-
ena in which there is no clear disease evidence, real tis- tions [26,27]. MF captures motor neuron’s myoelectric
sue damage or somatosensory system injury, causing signals through surface electrodes (extracellular tech-
fibromyalgia, regional pain complex, and nonspecific nique) or percutaneous (intracellular technique), con-
lumbar pain [7,8]. The transition from acute or chronic verting them into visual or auditory information that
MSP to NCP is associated with central sensitization provides patient immediate feedback on voluntary mus-
phenomena produced by changes in ion channels ex- cle contraction (VMC) or muscle activity at rest. MF
pression of nociceptive neurons, which triggers their electrodes perceive voltage changes in microvolts as-
greater excitability, reinforced synaptic transmission, sociated with neuromuscular activity, transmitting them
and decreased pain inhibition processes at the spinal to an amplifier and processor that filters, integrates,
cord posterior horn, subcortical and cortical areas such and rectifies bioelectric waves, transforming them into
as the thalamus, somatosensory cortex, or primary mo- digital signals represented graphically or audibly. This
tor cortex [5,9,10]. Furthermore, less neural connectiv- information is used to promote or decrease motor activ-
ity between the prefrontal cortex and somatosensory ity depending on whether the objective is to strengthen,
areas has been documented in patients with chronic relax or re-educate motor patterns [28].
MSP, along with more synaptic networks with the insu- Biological feedback processes are essential for hu-
la, which exacerbates the psychological and emotional man movement realization and regulation. Motor neu-
components [11,12]. rons activity is the result of the interaction between the
Currently, more than 150 musculoskeletal disorders central nervous system (CNS) and sensory function,
(MSD) have been recognized, highlighting degenera- through an intrinsic feedback system formed by neuro-
tive and autoimmune joint diseases, fractures, dislo- logical circuits between the motor system, propriocep-
cations, muscle injuries, sprains, and tendinopathies tors, joint receptors, skin receptors, vestibular system,
[1,2,6]. Most frequent presentations include the back, and visual system [28–30]. On the other hand, visual
neck, shoulders, and knees, although multiregional and/or auditory biofeedback favors the different levels
MSDs are also described [1,13]. MSD can debut at any of afferent and efferent integration in CNS, allowing
age; however, their prevalence increases from adoles- the patient to control motor activity [28].
cence onwards [14]. Even though the literature describes MF as a valu-
MSD medical treatment has been oriented to their able therapeutic resource, publications that support its
clinical symptoms with analgesic drugs, non-steroidal use for MSD have decreased in recent years, showing
anti-inflammatory drugs (NSAIDs), opiates or corti- greater development in neurological and pelvic floor re-
costeroids infiltration, which produce symptoms relief, habilitation, so an update in musculoskeletal rehabilita-
although they aren’t a functional improvement guar- tion is necessary. Thus, the objective of this systematic
antee, added to the fact that for some conditions their review (SR) was to describe the efficacy of MF in func-
efficacy and safety are uncertain [15,16]. In addition, tion recovery, strength increase and muscle relaxation
the overuse of drugs has been associated with analge- in MSD.
sic tolerance, hyperalgesia, and adverse effects, such as
nausea, vomiting, gastrointestinal irritation, arterial hy-
pertension, kidney problems, or hepatotoxicity [15–17]. Materials and methods
Surgery is an alternative for many MSD with refractory
symptoms or pharmacological treatment resistance, al- Study design
though its efficacy is dependent on clinical conditions, This SR adheres to the PRISMA statement on the
personal and contextual variables, added to patient eco- reporting of preference items for systematic reviews
nomic costs [15,18]. and meta-analysis (available at http://www.prisma-
Physical therapy is a non-pharmacological option statement.org) [31]. The research was uploaded elec-
for pain management and functional recovery in MSD, tronically to the International SR Prospective Regis-
using treatments such as therapeutic ultrasound (US), try (PROSPERO) of the National Institute for Health
transcutaneous electrical nerve stimulation (TENS), Research (NIHR), obtaining the identification code
photobiomodulation (PBM), manual therapy, and CRD42021228046.
Advances in Rehabilitation, 2022, 36(1), 41–69 43
The PICO acronym (participants, intervention, com- motion. The exclusion criteria were: (i) case report stud-
parison, and outcome) was used to structure the research ies, systematic reviews (SR), meta-analysis (MT) and
question and search algorithm based on the following literature reviews, (ii) animal-testing or in vitro studies,
elements: patients with MSD, intervened with MF, (iii) use of MF in non-musculoskeletal conditions, and
compared with a control, sham application or placebo, (iv) studies with incomplete abstracts or texts.
and evaluating, as main outcome, changes in function-
ality and, as secondary result, pain decrease, range of Article’s quality and risk of bias
motion (ROM) increase, or muscle strength. The articles’ internal validity was determined with
the PEDro scale [33]. Each researcher performed an in-
Search strategy dependent assessment, and any disagreement was sub-
The SR was performed considering PubMed, Sco- sequently discussed to establish consensus. RCTs with
pus, Web of Science (WoS), Cinahl, and Science Direct scores less than five were classified as “low quality,”
electronic databases with the last update on September while scores greater than or equal to 5 were considered
2, 2021. For the search, keywords from the MeSH dic- “high quality.”
tionary were chosen (Medical Subject Headings, https:// Risk of bias was assessed using the RoB.2 tool
www.ncbi.nlm.nih.gov/mesh). Search terms included (Cochrane Collaboration tool for RCT analysis in SR)
“Biofeedback”, “Myofeedback”, “Myoelectric biofeed- for the following domains [34]; (1) bias arising from
back”, “Rehabilitation”, “Recovery of Function” and randomization process, (2) bias due to deviations from
“Musculoskeletal Diseases” connected through the bool- planned interventions, (3) bias due to missing outcome
ean terms “OR” and “AND” obtaining the following al- data, (4) outcome measurements bias, (5) bias in report-
gorithm: ((((“Biofeedback”) OR (“Myofeedback”)) OR ed outcome selection, and (6) overall article bias. The
(“Myoelectric biofeedback”)) AND ((“Rehabilitation”) investigators rated the risk of bias for each criterion as
OR (“Recovery of Function”))) AND ((“Musculoskel- high, low, unclear, or no information in case the data
etal Diseases”) OR (“Musculoskeletal Pain”)). provided were not sufficient to decide. Box and sum-
Searches for each database were downloaded (nbib, mary plots were constructed with the Robvis tool [35].
ris or ciw formats) and the files were analyzed with the Studies with two or more high risks of bias were con-
Rayyan tool developed for the preliminary selection of sidered as low quality [34].
abstracts and article titles (https://www.rayyan.ai) [32].
Four independent researchers (AM, FL, CL, VN) ana-
lyzed articles titles and abstracts based on the selection Results
criteria, classifying them in the “included”, “maybe”
and “excluded” categories. In addition, the references Search results
of the studies were examined and revised in terms of Preliminary search strategy yielded a total of 5,141
their country of origin, author, affiliated institutions, articles for selected databases (Pubmed, n = 25; Scopus,
and enrollment periods to identify and exclude dupli- n = 2918; WoS, n = 10; Cinahl, n = 1494, and Science
cate publications. Articles in the “maybe” category Direct, n = 695). After reviewing titles and abstracts,
were reviewed by the research team to determine their 160 articles were classified as “possible” and “included”
inclusion in the final count. Articles with incomplete when applying selection criteria. The researchers reached
abstracts were discarded from the analysis, and each in- consensus on these articles, discarding 134 studies, and
vestigator recorded their reasons for exclusion. finally including 26 for analysis [22–25,35–55]. The
For included articles, study objective, PEDro scale main reasons for exclusion were surface electromyog-
score, participants demographic data, follow-up period, raphy studies, other types of studies, articles in another
evaluation time, treatment protocol with MF and results language, studies that addressed non-musculoskeletal
in the interest outcomes were analyzed [33]. conditions, and articles with incomplete or unavailable
abstracts. Figure 1 shows the PRISMA flow chart with
Selection criteria a summary of the screening results [57].
Inclusion criteria considered: (1) randomized clini-
cal trials (RCT), (2) human studies, (3) articles in Eng- Risk of bias and quality
lish or Spanish, (4) participants older than 18 years, (5) This SR rated 7.69% of articles (n = 2) as high
participants with MSD, (6), studies that used MF alone risk of bias [23,25,27,33,36,38,43,45], especially in
or with another intervention in MSD rehabilitation, (7) domains 1 and 2 for RoB.2 tool [56,57]. On the oth-
comparison with another treatment, sham, or placebo, er hand, 26.92% (n = 7) did not present risks of bias
(7) outcome measures including changes in function, for any of domains [22,24,26,28,35,37,42,44], while
muscle strength, muscle relaxation, pain, or range of 42.30% presented at least some concern, especially for
Records identified through database searching

Identification
Pubmed (n = 25); Scopus (n = 2918); Web of Science (n = 10); Cinahl (n = 1494);

Science Direct (n = 695)
Records after duplicates removed

(n = 2970)
Screening
Eligibility criteria
Records screened Records excluded
• Randomized clinical trials (n = 2970) (n = 3104)
(RCTs).
• Human studies.
• Articles in English or
Spanish. Full-text articles excluded,
• Participants over 18 years with reasons
Full-text articles assessed
of age. (n = 134)
Eligibility
for eligibility
• Participants with
(n = 160) • Surface electromyography
musculoskeletal disorders.
• Use of electromyographic studies (n = 65).
biofeedback alone or with • Other types of studies such
another intervention as a as case studies, systematic
treatment for the Studies included in reviews/meta-analyzes,
rehabilitation of literature reviews (n = 11).
quantitative synthesis
musculoskeletal disorders. • Studies with incomplete
• Comparison with another (meta-analysis)
abstracts or texts (n = 2).
treatment, sham (n = 0) • Studies that treated non-
application or placebo. musculoskeletal conditions
Included
• Outcome measures that (neurological conditions and

include changes in pelvic floor dysfunctions)
functionality / disability, (n = 51).
pain, range of motion, or Studies included in
• Articles in another language
muscle strength. qualitative synthesis
(n = 1).
(n = 26)
Fig. 1. Flowchart of included studies in accordance with PRISMA guidelines
random assignment. Figure 2 summarizes risk of bias (SAIS) (n = 2, 12.5%), patellofemoral pain syndrome
of the selected articles. (PFPS) (n = 2, 12.5%), anterior cruciate ligament re-
Table 1 shows the PEDro score for the 26 RCT. In- construction (ACLR) (n = 2, 12.5%), knee osteoarthri-
ternal validity shows that 65.38% of articles (n = 17) tis (OA) (n = 5, 31.25%), non-surgical meniscal injuries
are of high quality (score greater than or equal to 5 for (n = 3, 18.75%) and nucleus hernia pulposus (n = 1,
PEDro scale) with an average of 7 points for all the ar- 6.25%) [22,23,35–48]. On the other hand, MF muscle
ticles [33]. relaxation studies included cervicobrachialgia (n = 3,
30.00%), neck pain (n = 2, 20.00%), whiplash syndrome
Study characteristics (WPS) (n = 2, 20.00%), cervical radiculopathy (n = 1,
Studies were grouped in Tables 2 and 3 according 10.00%), fibromyalgia (n = 1, 10.00%), low back pain
to their MF therapeutic aim (strengthening or muscle syndrome (LBPS) (n = 1, 10.00%) [24,25,49–56].
relaxation), summarizing the characteristics of 26 RCT Six studies (23.07%) used MF in experimental groups
in study groups, evaluation sessions, treatment ses- (EG) without other added treatment [41,50,51,54–56],
sions and the outcome measures of the variables of in- while the remaining ones applied MF combined with
terest. Table 2 shows that 16 articles (61.53%) report another treatment. Isolated MF applications were main-
MF for muscle strengthening, while table 3 shows 10 ly aimed at achieving muscle relaxation in neck pain,
studies for muscle relaxation (38.46%). Strengthening cervicobrachialgia, and LBPS [50,51,55,56], while on-
MF studies included post-arthroscopic meniscal injury ly Choi (2015) applied isolated MF for strengthening in
(n = 4, 25.00%), subacromial impingement syndrome knee OA [41].
Fig. 2. Risk of bias for the selected studies (ROBVIS tool)

Tab. 1. PEDro scale scores of analyzed studies
Clinical PEDro scale criteria

Total
trial Author, year of publication
1 2 3 4 5 6 7 8 9 10 11 score
number
1 Akkaya, 2012 [22] 0 1 1 1 0 0 1 1 0 1 1 7
2 Juul-Kristensen, 2019 [23] 1 1 1 1 0 0 1 1 1 1 1 8
3 Baumueller, 2007 [24] 1 1 0 0 1 0 0 1 0 1 1 5
4 Gálvez-Hernández, 2016 [25] 1 0 0 0 0 0 0 0 0 1 0 1
5 Oravitan, 2013 [35] 0 1 0 1 0 0 0 0 0 1 1 4
6 Huang, 2013 [36] 1 0 0 1 1 0 0 1 0 1 1 5
7 Ng. 2008 [37] 0 1 0 1 0 0 1 1 0 0 1 5
8 Draper, 1997 [38] 0 1 0 0 0 0 0 0 0 1 0 2
9 Anwer, 2011 [39] 0 1 0 0 1 0 0 0 1 1 1 5
10 Dursun, 2001 [40] 1 1 0 1 0 0 0 1 0 1 1 5
11 Choi, 2015 [41] 1 1 0 1 0 0 0 0 0 1 1 4
12 Yilmaz, 2010 [42] 1 1 0 1 0 0 0 1 0 1 1 5
13 Durmus, 2007 [43] 1 1 0 1 0 0 0 1 0 1 1 5
14 Christanell, 2012 [44] 1 0 0 1 0 0 0 1 0 1 1 4
15 Sardaru, 2018 [45] 1 1 0 1 0 0 0 1 1 1 1 6
16 Kirnap, 2005 [46] 0 1 0 1 0 0 0 1 0 1 1 5
17 Levitt, 1995 [47] 1 0 0 1 0 0 0 0 0 1 1 3
18 Raeissadat, 2018 [48] 1 1 0 1 0 0 1 1 1 1 1 7
19 Ehrenborg, 2010 [49] 1 0 0 1 0 0 0 1 1 1 1 5
20 Dellve, 2011 [50] 1 1 1 1 0 0 0 0 0 1 1 5
21 Voerman [51] 1 1 0 1 0 0 0 1 1 0 1 5
22 Atteya, 2004 [52] 1 1 0 1 0 0 0 1 1 0 1 5
23 Eslamian, 2020 [53] 1 1 1 1 0 0 1 1 1 1 1 8
24 Newton, 1995 [54] 1 0 0 1 0 0 0 0 0 1 1 3
25 Kosterink, 2010 [55] 1 1 0 1 0 0 0 0 0 1 1 4
26 Spence, 1995 [56] 0 1 0 0 0 0 0 1 0 1 1 4
PEDro (Physiotherapy Evidence Database) scale criteria:

(1) The selection criteria were specified.
(2) Subjects were randomized into groups (in a crossover study, subjects were randomized as they received treatments).
(3) The assignment was hidden.
(4) The groups were similar at the beginning in relation to the most important prognostic indicators.
(5) All subjects were blinded.
(6) All therapists who administered the therapy were blinded.
(7) All assessors who measured at least one key outcome were blinded.
(8) Measures of at least one of the key outcomes were obtained from more than 85% of the subjects initially assigned to the groups.
(9) Results were presented for all subjects who received treatment or were assigned to the control group, or, when this could not be the
case, data for at least one key outcome were analysed by ‘intention to treat’.
(10) Results of statistical comparisons between groups were reported for at least one key outcome.
(11) The study provides point and variability measures for at least one key outcome.
Tab 2. Characteristics of muscle strengthening MF studies
Clinical Study Autor Musculoskeletal Sample size (n) EG and CG Intervention MF sessions Evaluations Outcomes Conclusion
trial Year condition men women (women; and treatment
number Country mean age ± DE men) time
(years)
1 Efficacy of Akkaya Meniscal injury n = 45 EG = 15 EG = QF MF + exercise Sessions: T0: baseline Walking pain intensity Walking pain intensity (VAS)
electromyographic [2012] Men = 19 (10 women; program (Phase 1: 10 sessions (before (VAS) EG: T2* < T1* < T0
biofeedback Turkey Women = 26 5 men) hamstring stretching, (5 weekly surgery) CG 1: T0 < T1* < T2*
and electrical 47 ± 11.6 CG1 = 15 drainage exercises; sessions) – 2 T1: week 2 Running speed CG 2: T0 < T1* < T2*
stimulation (7 women; Phase 2: ABD and ADD weeks total (10 sessions) (2-MWT) EG = CG 1 = CG 2 for T0,
following 8 men) exercises, knee flexion T2: week 6 T1 y T2
arthroscopic partial CG2 = 15 and extension, QF and Treatment (30 sessions) Functionality (Lyshom Running speed (2-MWT)
meniscectomy: (9 women; GN stretching exercises; time:NS scale) EG: T2 > T1 > T0
a randomized 6 men) Phase 3: CKC exercises CG 1: T2 > T1 > T0
controlled trial [22]. lower limb, progressive Flexion and extension CG 2: T2 >T1 > T0
resistance exercises). ROM (goniometer) EG = CG 1 = CG 2 for T0,
CG 1 = Exercise T1 y T2
Advances in Rehabilitation, 2022, 36(1), 41–69
program (Phase 1: Edema (perimetry) Functionality (Lyshom scale)

hamstring stretching, EG: T2* > T1* > T0
drainage exercises; Quadriceps femoris CG 1: T2* > T1* > T0
Phase 2: hip ABD and muscle strength CG 2: T2* > T1* > T0
ADD exercises, knee (EMG) EG > CG 1 = CG 2 for T1*
flexion and extension, EG = CG 1 = CG 2 for T0
QF and GN stretching and T2
exercises; Phase 3: Flexion and extension ROM
lower limb CKC (goniometer)
exercises, progressive EG: T2* > T1 > T0
resistance exercises). CG 1: T2 > T1 < T0
CG 2 = NMES + CG 2: T2* > T1 > T0
exercise program (Phase Edema (perimetry)
1: hamstring stretching, Not reported
drainage exercises; Quadriceps femoris muscle
Phase 2: hip ABD and strength (EMG)
ADD exercises, knee EG: T2* > T1* > T0
flexion and extension, CG 1: T2 > T1 > T0
QF and GN stretching CG 2: T2 > T1 > T0
exercises; lower, EG > CG 1 = CG 2 for T0,
progressive resistance T1 and T2
exercises).
47
Clinical Study Autor Musculoskeletal Sample size (n) EG and CG Intervention MF sessions Evaluations Outcomes Conclusion 48
(years)
2 Positive effects Juul- SAIS n = 49 EG = 26 EG = UT, MT, LT and Sessions: T0: baseline Pain intensity (NPRS) Pain intensity (NPRS)
of neuromuscular Kristensen Men = 24 (NS) SA MF + exercise 40 sessions (before Disability EESS EG: T1 < T0
shoulder [2019] Women = 25 CG = 23 protocol (phase 1: (5 per week) treatment) (DASH) CG: T1 < T0
exercises with or Denmark 43 ± NS (NS) scapular stabilization – 8 weeks T1: 8 weeks Functionality (OSS) EG < CG for T1*
without EMG- and stretching exercises; total Electromyographic Disability EESS (DASH)
biofeedback, on phase 2: functional activity UT, MT, LT EG: T1* < T0
pain and function resistance exercises with Treatment and SA (EMG) CG: T1* < T0
in participants scapular stabilization). time: EG = CG for T0
with subacromial CG = exercise protocol 4 to 6 Functionality (OSS)
pain syndrome (phase 1: scapular minutes EG: T1* > T0
– A randomised stabilization and (30 seconds CG: T1* > T0
controlled trial [23] stretching exercises; of contraction EG = CG for T0
phase 2: functional and 60 Electromyographic activity
resistance exercises with seconds of UT, MT, LT and SA (EMG)
scapular stabilization). relaxation) EG: T1 > T0
CG: T1 > T0
EG = CG for T0
3 The Oravitan Meniscal injury n = 64 EG = 33 EG = QF and HS MF + Sessions: T0: baseline Pain intensity (KOOS) Pain intensity (KOOS)
Effectiveness of [2013] Men = 43 (11 women; rehabilitation program 40 sessions (before Knee functionality EG: T1 > T0
Electromyographic Romania Women = 21 22 men) (mobility exercises, (5 per week) treatment) (KOOS) CG: T1 > T0
Biofeedback 35 ± 6.5 CG = 31 partial weight bearing, – 8 weeks T1: 8 weeks Knee flexor and EG = CG for T1
as Part of (10 women; total weight bearing, total (40 sessions) extensor strength Knee functionality (KOOS)
a Meniscal Repair 21 men) scar mobilization, (MD) EG: T1 > T0
Rehabilitation NMES, cryotherapy, Treatment Electromyographic QF CG: T1 > T0
Programme [35] stretching and time: activity (EMG) EG > CG for T1* (sports and
coordination exercises). 20 minutes HS electromyographic recreational activities item)
CG = rehabilitation (20 seconds activity (EMG) Knee flexor and extensor
program (mobility of contraction strength (MD)
exercises, partial and 5 seconds EG: T1 > T0
weight bearing, total of relaxation) CG: T1 > T0
weight bearing, scar EG = CG for T1
mobilization, NMES, Electromyographic QF
cryotherapy, stretching activity (EMG)
and coordination EG: T1* > T0
exercises). CG: T1 > T0
EG > CG for T1*
HS electromyographic
activity (EMG)
EG: T1 > T0*
CG: T1 > T0
EG > CG for T1*
de la Barra Ortiz HA, Matamala AM, Lopez Inostroza F, et al.
(years)
4 EMG biofeedback Huang SAIS n = 25 GE 1 = 13 EG 1 = UT, MT, LT Sessions: T0: baseline MVC relationship MVC relationship between
effectiveness to [2013] Men = NS (NS) and SA MF + resistance 1 session (before between UT, MT, LT UT, MT, LT and SA for
alter muscle activity Taiwan Women = NS GE 2 = 12 exercises (shoulder treatment) and SA for shoulder shoulder flexion (EMG)
pattern and scapular 24 ± 3.6 (NS) flexion movements, Treatment T1: end of flexion (EMG) EG 1: T1 < T0
kinematics in CG 1 = 13 shoulder external time: treatment MVC relationship EG 2: T1 < T0
subjects with and (NS) rotation and KPP) + 4 minutes between UT, MT, LT CG 1: T1 > T0
without shoulder CG 2 = 12 scapular exercises (6 seconds and SA for external CG 2: T1 > T0
impingement [36] (NS) (scapular upward and for each rotation of the CG 1 y CG 2 > EG 1 y EG
posterior tilt). repetition, 3 shoulder (EMG) 2 for T1
EG 1: EG 2 = UT, MT, LT repetitions for MVC relationship MVC relationship between
participants and SA MF + resistance each exercise between UT and SA UT, MT, LT and SA for
with SAIS exercises (shoulder except for (EMG) external rotation of the
EG 2: flexion movements, KPP; 1 Scapular kinematics of shoulder (EMG)
healthy shoulder external minute rest upward and posterior EG 1: T1 < T0
participants rotation and KPP) + between each tilt (EMG) EG 2: T1 < T0

CG 1: scapular exercises exercise). CG 1: T1 > T0
participants (scapular upward and CG 2: T1 > T0
with SAIS posterior tilt). GC 1 y GC 2 > GE 1 y GE
CG 2: CG 1 = resistance 2 para T1
healthy exercises (shoulder MVC relationship between
participants flexion movements, UT and SA (EMG)
shoulder external EG 1: T1 < T0
rotation and KPP) + EG 2: T1 < T0
scapular exercises CG 1: T1 > T0
(scapular upward and CG 2: T1 > T0
posterior tilt). GC 1 y GC 2 > GE 1 y GE
CG 2 = resistance 2 para T1
exercises (shoulder Scapular kinematics of
flexion movements, upward and posterior tilt
shoulder external (EMG)
rotation and KPP) + EG 1: T1* > T0
scapular exercises EG 2: T1* > T0
(scapular upward and CG 1: T1 > T0
posterior tilt). CG 2: T1 > T0
EG 1 y EG 2 > CG 1 y CG
2 for T1*
49
(years)
5 Biofeedback Ng PFPS n = 26 EG = 13 EG = QF MF Sessions: T0: baseline EMG activity EMG activity relationship
exercise improved [2008] Men = 10 (NS) + therapeutic 40 sessions (5 (before relationship between between VMO/VLM (EMG)
the EMG activity China Women = 16 CG = 13 exercises (warm- per week) – 8 treatment) VMO/VL (EMG) EG: T1* > T0
ratio of the medial 38 ± NS (NS) up, strengthening, weeks total T1: 8 weeks CG: T1 > T0
and lateral vasti proprioceptive exercises (end of
muscles in subjects and agility exercises) Treatment treatment)
with patellofemoral CG = Therapeutic time:
pain syndrome [37] exercises (warm- 30 minutes
up, strengthening,
proprioceptive exercises
and agility exercises)
6 Electrical Draper ACLR n = 30 EG = 15 (6 EG = QF MF exercises Sessions: T0: baseline Knee Extension ROM Knee Extension ROM (GM)
Stimulation Versus [1997] Men = 16 women; 9 (weeks 1 and 2: isotonic 20 sessions (before (GM) EG: T4 > T3 > T2 > T1 > T0
Electromyographic USA Women = 16 men) resistance exercises, (5 sessions treatment) QF torque ratio CC: T4 > T3 > T2 > T1 > T0
Biofeedback in 25 ± 7.8 CG = 15 (8 week 3 and 4: isometric per week) – 4 T1: week 1 between healthy and EG = CG for T4-T1
the Recovery of women; 7 exercises, week 5 and weeks total T2: week 2 operated limb (IE)
Quadriceps Femoris men) 6; isokinetic exercises) T3: week 4 QF torque ratio between
Muscle Function + SLR Treatment T4: week 6 healthy and operated limb
Following Anterior CG = QF NMES + QF time: (IE)
Cruciate Ligament quadriceps exercises 30 minutes EG: T4 > T3 > T2 > T1 > T0
Surgery [38] (weeks 1 and 2: isotonic (10 seconds CG: T4 > T3 > T2 > T1 > T0
resistance exercises, of contraction EG = CG for T4-T1
week 3 and 4: isometric and 20
exercises, week 5 and seconds of
6; isokinetic exercises) relaxation, 3
+ SLR times a day)
7 Effectiveness of Anwer Knee OA n = 33 EG = 17 (11 EG = QF MF + HP Sessions: T0: baseline QF isometric strength QF isometric strength at 60 °
electromyographic [2011] Men = 10 women; 4 CG = QF sham MF 25 sessions (before at 60 ° flexion (DM) flexion (DM)
biofeedback India Women = 23 men) + HP (5 weekly treatment) EG: T3* > T2* > T1 > T0
training on 53 ± 7.73 CG = 16 (10 sessions) – 5 T1: week 2 CG: T3 = T2 = T1 > T0
quadriceps women; 5 weeks total T2: week 3 EG > CG for T3 and T2
muscle strength in men) T3: week 5
osteoarthritis of Treatment
knee [39]. time:
NS
(years)
8 Electromyographic Dursun PFPS n = 60 EG = 24 GE = QF MF + Sessions: T0: baseline Pain intensity (VAS) Pain intensity (VAS)
biofeedback- [2001] Men = 12 (18 women; exercise program 12 sessions (before Disability (FCI) EG: T3 < T2 < T1 < T0
controlled exercise Turkey Women = 48 6 men) (CKC isometric (4 weekly treatment) VMO MVC and CG: T3 < T2 < T1 < T0
versus conservative 37 ± 9.2 CG = 24 exercises, flexibility, sessions) – 4 T1: 4 weeks AMVC (EMG) EG = CG for T3, T2 y T1
care for (18 women; proprioception and weeks total T2: 8 weeks VL MVC and AMVC Disability (FIC)
patellofemoral pain 6 men) resistance training on T3: 12 weeks (EMG) EG: T3 > T2 > T1
syndrome [40]. a cycle ergometer). Treatment CG: T3 > T2 > T1
CG = Exercise program time: EG = EG for T3, T2 y T1
(CKC isometric 30 minutes VMO MVC and AMVC
exercises, flexibility, (10 seconds (EMG)
proprioception and of contraction EG: T3 > T2 > T1
resistance training on and 20 CG: T3 > T2 > T1
a cycle ergometer). seconds of EG = EG for T3, T2 y T1
relaxation) VL MVC and AMVC (EMG)

EG: T3 > T2 > T1
CG: T3 > T2 > T1
EG > CG for T2*
9 Effects of isometric Choi Knee OA n = 30 EG = 10 EG = QF MF Sessions: T0: baseline Pain intensity (VAS) Pain intensity (VAS)
exercise using [2015] Men = 0 (10 women; CG 1 = QF exercises 24 sessions (before MIVC (DM) EG: T1* < T0
biofeedback Korea Women = 30 0 men) CG 2 = HP + US + (3 weekly treatment) VMO thickness (USG) CG 1: T1* < T0
on maximum 72 ± 8.8 CG 1 = 10 TENS sessions) – 8 T1: 8 weeks CG 2: T1* < T0
voluntary isometric (10 women; weeks total (after CG 2 < EG < CG 1 for T1*
contraction, 0 men) treatment) MIVC (DM)
pain, and muscle CG 2 = 10 Treatment EG: T1* > T0
thickness in (10 women; time: CG 1: T1* > T0
patients with knee 0 men) 20 minutes CG 2: T1 < T2
osteoarthritis [41]. (5 seconds of EG = CG 1 > CG 2 for T1*
contraction VMO thickness (USG)
and 5 seconds EG: T1* > T0
of relaxation) CG 1: T1 > T0
CG 2: T1 < T2
EG > CG 1 > CG 2 for T1*
51
(years)
10 Efficacy of EMG- Yilmaz Knee OA n = 40 EG = 19 EG = QF MF + Sessions: T0: baseline Pain intensity at rest, Pain intensity at rest, walking
biofeedback in knee [2010] Men = 5 (17 women; isometric exercises 9 sessions (before walking and climbing and climbing stairs (VAS)
osteoarthritis [42] Turkey Women = 35 2 men) (CKC fot QF and hip (3 weekly treatment) stairs (VAS) EG: T1* < T0
58 ± 7.7 CG = 20 ADD) + progressive sessions T1: 3 weeks Knee ROM CG: T1* < T0
(17 women; resistance exercises twice a day) – (after (goniometry) EG = CG for T1
3 men) (OKC without load 3 weeks total treatment) QF isokinetic strength Knee ROM (goniometry)
for week 1, 0.5 kg for (EI) NS
week 2 and 1.5 kg for Treatment Disability (WOMAC) QF isokinetic strength (EI)
week 3). time: Subjective Health EG: T1* > T0 (physical
CG = Isometric NS Perception (NHS) activity, pain, sleep and
exercises (CKC fot energy domains)
QF and hip ADD) + CG: T1* > T0 (physical
progressive resistance activity and pain domains)
exercises (OKC without EG = CG for T1 (sleep and
load for week 1, 0.5 kg energy domains)
for week 2 and 1.5 kg Disability (WOMAC)
for week 3). EG: T1* < T0
CG: T1* < T0
EG = CG for T1
Subjective Health Perception
(NHS)
EG: T1* < T0
CG: T1* < T0
EG = GC for T1
11 Effects of Durmus Knee OA n = 50 EG = 25 (25 EG = QF MF + Sessions: T0: baseline Pain intensity at rest Pain intensity at rest and
quadriceps [2007] Men = 0 women; 0 isometric exercises 20 sessions (before and activity (VAS) activity (VAS)
electrical Turkey Women = 50 men) CG = QF NMES (5 sessions treatment) Disability (WOMAC) EG: T1* < T0
stimulation 57 ± 1.77 CG = 25 (25 per week) – 4 T1: 4 weeks Functionality (50- CG: T1* < T0
program on clinical women; 0 weeks total (after MWT) Disability (WOMAC)
parameters in the men) treatment) Muscle strength (RM EG: T1* < T0
patients with knee Treatment and 10RM) CG: T1* < T0
osteoarthritis [43] time: Functionality (50-WMT)
20 minutes EG: T1* < T0
(10 seconds CG: T1* < T0
of contraction Muscle strength (RM and
and 50 10RM)
seconds of EG: T1* > T0
relaxation) CG: T1* >T0
(years)
12 The influence of Christanell ACLR n = 16 EG = 8 (NS) EG = QF MF + Sessions: T0: baseline Pain intensity (VAS) Pain intensity (VAS)
electromyographic [2012] Men = 12 CG = 8 (NS) therapeutic exercises 16 sessions (before Knee edema (rating EG: T4 < T3-T1
biofeedback therapy Swiss Women = 4 (isometric, isotonic and (3 weekly treatment) scale) CG: T4 < T3-T1
on knee extension 30 ± NS balance exercises) + sessions T1: week 1 Heel Height (HHD) EG = CG for T4-T1
following anterior postoperative protocol the first 4 T2: week 2 Knee flexion and Knee edema (rating scale)
cruciate ligament (NMES, manual weeks and 2 T3: week 4 extension ROM EG: T4 < T3-T1
reconstruction: lymphatic drainage, sessions the T4: week 6 (goniometry) CG: T4 < T3-T1
A randomized water exercises) last 2 weeks) VMO EG = CG for T4-T1
controlled trial [44] CG = Postoperative – 6 weeks Electromyographic Heel Height (HHD)
protocol (NMES, total activity (EMG) EG: T4* < T3-T1
manual lymphatic Functionality (IKDC) CG: T4 < T3-T1
drainage, water Treatment EG < CG for T4-T1*
exercises) time: Knee flexion and extension
NS ROM (goniometry)
EG: T4 > T3-T1*
CG: T4 > T3-T1
EG > CG forT4-T1*
VMO Electromyographic
activity (EMG)
EG: T4 > T3-T1*
CG: T4 > T3-T1
EG > CG for T4-T1
Functionality (IKDC)
EG: T4 > T3-T1
CG: T4 > T3-T1
GE = GC para T4-T1
13 Effects of Sardaru Lumbar nucleus n = 50 EG = 35 EG = TA MF + TA FES Sessions: T0: baseline NCV (EMG) NCV (EMG)
biofeedback versus [2018] pulposus hernia Men = 26 (11 women; CG = TA FES 20 sessions (before CMAP (EMG) EG: T1 = T0
switch-triggered Romania Women = 24 14 men) (5 weekly treatment) TA muscle strength CG: T1 = T0
functional electrical 40 ± NS CG = 25 sessions) – 4 T1: week 4 (DM) EG = CG for T1
stimulation on (13 women; weeks total Functionality (ODI) CMAP (EMG)
sciatica-related foot 12 men) EG: T1 > T0
drop [45] Treatment CG: T1 > T0
time: EG > CG for T1*
30 minutes TA muscle strength (DM)
EG: T1 > T0
CG: T1 > T0
EG > CG for T1*
Functionality (ODI)
EG: T1* < T0
CG: T1 < T0
EG < CG for T1*
53
(years)
14 The efficacy of Kirnap Meniscal injury n = 40 EG = 20 EG = QF MF + home Sessions: T0: baseline Functionality Functionality (Lysholm scale)
EMG-biofeedback [2005] Men = 40 (0 women; exercise program 30 sessions (5 (before sur- (Lysholm scale) EG: T3* > T2* > T1 < T0
training on Turkey Women = 0 20 men) (3 phases; P1 = times a week) gery) QF circumference CG: T3* > T2* > T1 < T0
quadriceps muscle 35 ± 10.3 CG = 20 cryotherapy + isometric – 6 weeks T1: 3 days (perimetry) EG > CG for T2* y T1*
strength in patients (0 women; exercises QF + patella total after surgery. Knee flexion passive QF circumference
after arthroscopic 20 men) mobilization and SLR, T2: week 2 ROM (goniometry) (perimetry)
meniscectomy [46] P2 = ADD and QF Treatment T3: week 6 MVC ratio of VMO Not reported
strengthening, and P3 time: between operated and Knee flexion passive ROM
= CKC lower limb 5 minutes (5 non-operated limb (goniometry)
exercises and step side). seconds of (EMG) EG: T3* > T2* > T1 < T0
CG = Home exercise contraction MVC ratio of VL CG: T3* > T2* > T1 < T0
program (3 phases; P1 = and 10 between operated and EG > CG for T2* y T1*
cryotherapy + isometric seconds of non-operated limb MVC ratio of VMO between
exercises QF + patella relaxation) (EMG) operated and non-operated
mobilization and SLR, limb (EMG)
P2 = ADD and QF EG: T3* > T2* > T1 < T0
strengthening, and P3 CG: T3 > T2 > T1 < T0
= CKC lower limb EG > GC for T2* y T1*
exercises and step side). MVC ratio of VL between
operated and non-operated
limb (EMG)
GE: T3* > T2* > T1 < T0
GC: T3 > T2 > T1 < T0
GE > GC for T2* y T1*
15 EMG feedback- Levitt Meniscal injury n = 51 EG = 28 EG = QF MF + Sessions: T0: baseline QF activity (EMG) QF activity (EMG)
assisted [1995] Men = 35 (7 women; isometric exercises at 10 sessions (before ROM (IE) EG: T1* > T0
postoperative USA Women = 16 21 men) home (3 times a day) (daily) – 2 surgery) Isokinetic QF strength CG: T1 > T0
rehabilitation of 26 ± 15 CG = 23 CG = isometric weeks total T1: 10 days (IE) EG > CG for T1*
minor arthroscopic (9 women; exercises at home (3 (post-surgery) Post-surgery pain ROM (IE)
knee surgeries [47] 14 men) times a day) Treatment intensity (NPRS) EG: T1* > T0
time: CG: T1 > T0
NS EG > CG for T1*
Isokinetic QF strength (IE)
EG: T1* > T0
CG: T1 > T0
EG > CG for T1*
Post-surgery pain intensity
(NPRS)
EG: T1 < T0
CG: T1 < T0
EG = CG for T1
(years)
16 The efficacy of Raeissadat Knee OA n = 46 EG = 21 EG = QF MF + Sessions: T0: baseline Pain intensity (VAS) Pain intensity (VAS)
electromyographic [2018] Men = 7 (women 19; isometric exercises 12 sessions – (before VMO Thickness EG: T1* < T0
biofeedback on Iran Women = 39 men 2) CG = isometric 8 weeks total treatment) (USG) CG: T1* < T0
pain, function, and 61 ± 7.9 CG = 23 exercises T1: week 8 Electrical activity VL EG < CG for T1*
maximal thickness (women 16; Treatment (EMG) VMO Thickness (USG)
of vastus medialis men 4) time: Functionality EG: T1= T0
oblique muscle 15 minutes (WOMAC) CG: T1 = T0
in patients with (5 seconds of Functionality EG = GC for T1
knee osteoarthritis: contraction (Lequesne index) Electrical activity VL (EMG)
a randomized and 10 EG: T1* > T0
clinical trial [48] seconds of CG: T1* > T0
relaxation) EG = CG for T1
Functionality (WOMAC)
EG: T1* < T0
CG: T1* < T0

EG < CG for T1*
Functionality (Lequesne
index)
EG: T1* < T0
CG: T1* < T0
EG = CG for T1
2-MWT, two meters walking test; 10RM, 10 maximum resistance; 50-MWT, fifty meters walking test; ACLR, Anterior cruciate ligament reconstruction; ABD, hip abductor muscles; ADD,
hip adductor muscles; AMVC, average maximal voluntary contraction; CG, control groups; CKC, closed kinematic chain exercises; CMAP, compound action potential; DASH, the Disabilities
of the Arm, Shoulder and Hand questionnaire; DM, dynamometry; EG, experimental groups; EMG, surface electromyography; FES, functional electrical stimulation; FIC, functional capacity
index; GN, gastrocnemius muscles; HP, hot packs; HS, hamstring muscles; IE, isokinetic evaluation; IKDC, international knee documentation Committee; KPP, knee push-up plus; KOOS, Knee
injury and Osteoarthritis Outcome Score; MVC, maximum voluntary contraction; MIVC, maximum isometric voluntary contraction; MF, myofeedback; MT, middle trapezius muscle; NCV,
nerve conduction velocity; NHS, Nottingham Health Profile; NMES, neuromuscular electrical stimulation; NPRS, numeric pain rating scale; NS, not specified; OA, LT, lower trapezius muscle;
ODI, Oswestry Disability Index; Osteoarthritis; OKC, open kinematic chain exercise; OSS, the Oxford Shoulder Score; PFPS, Patellofemoral pain syndrome; QF, quadriceps femoris muscle;
RCT, randomized clinical trial; RM, maximum resistance; ROM, range of movement; SA, serratus anterior muscle; SAIS, subacromial impingement syndrome; SLR, straight leg raising; TA,
tibialis anterior muscle; UT, upper trapezius muscle; US, therapeutic ultrasound; USG, ultrasonography; VAS, visual analogue scale; VMO, vastus medialis oblique muscle; VL, vastus lateralis
muscle; *p < 0.05.
55
Tab 3. Characteristics of muscle relaxation MF studies 56
Clinical Study Autor Musculoskeletal Sample size (n) EG and CG Intervention MF sessions and Evaluations Outcomes Conclusion
trial Year condition men, women (women; treatment time
number Country mean age ± DE men)
(years)
1 Management Baumueller Fibromyalgia n = 36 EG = 18 EG = UT MF Sessions: T0: baseline Disability (FIC) Disability (FIC)
of patients with [2007] Men = NS (NS) + standard 14 sessions (before Pain intensity EG: T2 < T1< T0
fibromyalgia using Germany Women = NS CG = 18 treatment for (3 sessions treatment) in ST (self- CG: T2 < T1< T0
biofeedback: A ran- 40 ± NS (NS) fibromyalgia per week for 3 T1: week 8 surgery with EG = CG for T2 and T1
domized control trial CG = Standard weeks, 1 weekly (post-treatment) Likert 6 scale) TS Pain intensity (self-perception
[24] treatment for session for 5 T2: 12 weeks Pain intensity with Likert scale)
fibromyalgia weeks) follow-up (ALG) EG: T2 < T1< T0
– 8 weeks total Quality of life CG: T2 < T1< T0
(SF-36) EG = CG for T2 and T1
Treatment time: Depression Pain intensity (ALG)
15 minutes (BDI) GE: T1 > T0 (T2 not assessed)
GC: T1 > T0 (T2 not assessed)
GE > GC for T1*
Quality of life (SF-36)
EG: T2 > T1 > T0
CG: T2 > T1 > T0
EG = GC for T2 and T1
Depression (BDI)
EG: T2 < T1 < T0
CG: T2 < T1 < T0
EG = CG for T2 and T1
(years)
2 Biofeedback Gálvez- WPS n = 11 EG = 6 EG = UT MF Sessions: T0: baseline UT muscle UT muscle activity symmetry (EMG)
treatment for acute Hernández Men = 2 (5 women; + progressive 3 sessions (before activity EG: T1* < T0
whiplash patients [2016] Women = 9 1 man) relaxation (once a week) treatment) symmetry CG: T1 < T0
[25] Mexico 32 ± NS CG = 5 techniques – 3 weeks total T1: week 3 (EMG) UT resting muscle activity (EMG)
(4 women; CG = NT UT resting EG: T1 > T0
1 man) Treatment time: muscle CG: T1 > T0
60 minutes activity Anxiety (BDI)
(EMG) EG: T1 < T0
Anxiety (BDI) CG: T1 = T0
Depression Depression (BDI)
(BDI) EG: T1 < T0
Functionality CG: T1 = T0
(NDI) Functionality (NDI)
Pain intensity EG: T1 < T0
(VAS) CG: T1 = T0
Fear of Pain intensity (VAS)
movement EG: T1* < T0
(TSK) CG: T1 < T0
Fear of movement (TSK)
EG: T1 = T0
CG: T1 = T0
3 Is surface EMG Ehrenborg Cervicobrachialgia n = 65 EG = 36 EG = UT MF + Sessions: T0: baseline Occupational Occupational performance (COPM)
biofeedback an [2010] Men = 31 (NS) functional hand 8 sessions (2 (before performance EG: T2* > T1*
effective training Sweden Women = 34 CG = 29 exercises sessions per treatment) (COPM) CG: T2* > T1*
method for persons 39 ± 11.1 (NS) CG = functional week) – 4 weeks T1: week 4 to 6 Occupational EG = CG for T2 and T1
with neck and hand exercises total (after treatment) performance Occupational performance
shoulder complaints T2: week 24 satisfaction satisfaction (COPM)
after whiplash- Treatment time: (COPM) EG: T2* > T1*
associated disorders 15 minutes Psychosocial CG: T2* > T1*
concerning activities (5 minutes of functioning EG = CG for T2 and T1
of daily living and contraction and (MPI-S) Psychosocial functioning (MPI-S)
pain – a randomized 10 minutes of EG: T2* < T1* (only for pain
controlled trial [49]. rest) interference activities criteria)
CG: T2* > T1* (only for distraction
response criteria)
EG = CG for T2 and T1
57
trial Year condition men, women (women; and treatment
(years)
4 Myofeedback Dellve Neck pain n = 60 EG = 20 EG = UT MF Sessions: T0: baseline Job ability Job ability skills (WAI)
training and [2011] Men = 0 (20 women; CG 1 = protocol 16 sessions (before skills (WAI) EG: T2 < T1 > T0
intensive muscular Sweden Women = 60 0 men) of stretching (4 weekly treatment) Job ability CG 1: T2* > T1 > T0
strength training 48 ± NS CG 1 = 20 exercises, sessions) – 4 T1: 4 weeks skills CG 2: T2 < T1 > T0
to decrease pain (20 women; strengthening, weeks total (after treatment) (observation) CG 1 > CG 2 > EG for T2 and T1
and improve work 0 men) UE coordination T2: 12 weeks Pain intensity
ability among CG 2 = 20 and breathing Treatment time: (NPRS) Job ability skills (observation)
female workers (20 women; exercises 120 minutes Grip strength EG: T2* < T1 < T0
on long-term sick 0 men) CG 2 = No (DM) CG 1: T2 < T1 < T0
leave with neck intervention Dexterity CG 2: T2 > T1 < T0
pain: a randomized and gross EG > CG 1 > CG 2 for T1 and T2
controlled trial [50] movements
(PPT) Pain intensity (NPRS)
Self-reported EG: T2 < T1* < T0
mental health CG 1: T2 < T1 < T0
and vitality CG 2: T2* > T1 < T0
(COPSOQ) EG > CG 1 > CG 2 for T1 and T2
Grip strength (DM)

EG: T2 < T1 < T0
CG 1: T2 < T1 < T0
CG 2: T2 < T1 < T0
CG 2 < EG < CG 1 for T1 and T2
Dexterity and gross movements

(PPT)
EG: T2 < T1 < T0
CG 1: T2 < T1 < T0
CG 2: T2 < T1 < T0
CG 2 < EG < CG 1 for T1 and T2
Self-reported mental health and

vitality (COPSOQ)
EG: T2 < T1 > T0
CG 1: T2 > T1 > T0
CG 2: T2 < T1 < T0
CG 1 > EG > CG 1 for T1 and T2
(years)
5 Myofeedback Voerman WPS n = 40 EG = 14 (5 EG = UT Sessions: T0: baseline Pain intensity Pain intensity (VAS)
training and [2006] Men = 9 women; 9 MF (bilateral 8 sessions (before (VAS) GE: T1 < T0*
intensive muscular Netherlands Women = 5 men) application) (2 weekly treatment) Disability
strength training 39 ± 10.0 sessions) – 4 T1: week 4 (end (NDI) Disability (NDI)
to decrease pain weeks total of treatment) UT activation GE: T1 < T0
and improve work patterns (EMG)
ability among Treatment time: UT activation patterns (EMG)
female workers 120 minutes GE: T1 < T0*
on long-term sick
leave with neck
pain: a randomized
controlled trial [51]
6 Biofeedback traction Atteya Cervical n = 20 EG = 10 EG = HP + Sessions: T0: baseline PVM PVM EMG-A at C5 / C6 level
versus conventional [2004] radiculopathy Men = NS (NS) cervical traction 12 sessions (before EMG-A at C5 / before traction (EMG)
traction in cervical Saudi Arabia Women = NS CG = 10 + PVC MF (2 weekly treatment) C6 level before EG: T6 < T5-T1*
radiculopathy [52] 45 ± NS (NS) CG = HP + sessions) – 6 T1: week 1 traction (EMG) CG: T6 < T5-T1
cervical traction weeks total T2: week 2 PVM EG < CG for T6-T4*, T2* and T1*
T3: week 3 EMG-A at C5 /
Treatment time: T4: week 4 C6 level during PVM EMG-A at C5 / C6 level
20 minutes T5: week 5 traction (EMG) during traction (EMG)
T6: week 6 PVM EG: T6 < T1*
EMG-A at C5 CG: T6 < T1
/ C6 level after EG < CG for T6-T4*, T2* and T1*:
traction (EMG)
PVM EMG-A at C5 / C6 level after
traction (EMG)
EG: T6 < T1*
CG: T6 < T1
EG < CG for T6-T4*, T2* and T1*
59
Clinical Study Autor Musculoskeletal Sample size (n) EG and CG Intervention MF sessions and Evaluations Outcomes Conclusion 60
(years)
7 Relative Eslamian Neck pain n = 50 EG = 25 EG = UT, DA Sessions: T0: baseline Cervical Cervical functionality (NDI)
Effectiveness of [2020] Men = 11 (21 women; and PVC MF + 6 sessions (2 (before functionality EG: T2* < T1* < T0
Electroacupuncture Iran Women = 39 4 men) pharmacology times a week) – treatment) (NDI) CG: T2* < T1* < T0
and Biofeedback 40 ± 5.6 CG = 25 (meloxicam) 3 weeks in total T1: week 3 Neck pain CG < EG for T2 and T1
in the Treatment (18 women; + isometric T2: week 12 (VAS)
of Neck and Upper 7 men) exercises and Treatment time: TrPS Painful Neck pain (VAS)
Back Myofascial neck and shoul- 30 minutes pressure EG: T2* < T1* < T0
Pain: A Randomized der stretching (5 seconds of threshold CG: T2* < T1* < T0
Clinical Trial [53] exercises (3 sets contraction and (ALG) CG < EG for T2 and T1
of 10 repetitions, 10 of relaxation) Cervical spine
each repetition – 3 attempts per ROM (IM) TrPS Painful pressure threshold
of 5 seconds). muscle (ALG)
CG = acupuncture EG: T2* > T1* > T0
+ pharmacology CG: T2* > T1* > T0
(meloxicam) CG > GE for T2 and T1
+ isometric
exercises and Cervical spine ROM (IM)
neck and shoul- EG: T2* > T1* > T0
der stretching CG: T2* > T1* > T0
exercises (3 sets CG > EG for T2 and T1
of 10 repetitions,
each repetition
of 5 seconds).
8 Cognitive- Newton J. LBPS n = 44 EG = 16 EG = UT and Sessions: T0: baseline Depression Depression (BDI)
Behavioural Therapy y cols. Men = 17 (NS) SE MF 8 sessions (2 (before (BDI) EG: T2 < T1< T0
versus EMG [1995] Women = 27 CG 1 = 16 CG 1 = CBT times a week) – treatment) Anxiety (STAI) CG 1: T2 < T1< T0
Biofeedback in the Australia 46 ± NS (NS) CG 2 = WLC 4 weeks total T1: week 4 Behavioral CG 2: T2 = T1 = T0
treatment of chronic CG 2 = 12 (end of strategies for EG < CG 1 < CG2 for T2*
low back pain [54] (NS) Treatment time: treatment) coping with Anxiety (STAI)
60 minutes T2: 24 weeks pain (CSQ) EG: T2 < T1< T0
(follow-up) Disability (PDI) CG 1: T2 < T1< T0
Beliefs about CG 2: T2 = T1 = T0
pain (PBQ) EG = CG 1 < CG 2 for T2
General Behavioral strategies for coping
Activity Level with pain (CSQ)
(GALS) EG: T2* > T1> T0
Daily pain CG 1: T2 > T1> T0
(self-report) CG 2: T2 = T1 = T0
EG = CG 1 < CG 2 for T2
(years)
8 Disability (PDI)
EG: T2* < T1< T0
CG 1: T2 < T1< T0
CG 2: T2 = T1 = T0
EG < CG 1 < CG 2 for T2*
Beliefs about pain (PBQ)

EG: T2* < T1< T0
CG 1: T2 < T1< T0
CG 2: T2 = T1 = T0
General Activity Level (GALS)

EG: T2 > T1> T0
CG 1: T2 > T1> T0
CG 2: T2 = T1 = T0
EG = CG 1 < CG 2 for T2
Daily pain (self-report)

EG: T2* < T1< T0
CG 1: T2 < T1< T0
CG 2: T2 = T1 = T0
9 The clinical Kosterink Cervicobrachialgia n = 71 EG = 36 EG = UT MF Sessions: T0: baseline Pain intensity Pain intensity (VAS)
effectiveness of [2010] Men = 0 (36 women; (TRH and 20 sessions (5 (before (VAS) EG: T1 < T0
a myofeedback- Netherlands Women = 71 0 men) face-to-face times a week) – treatment) Disability (PDI) CG: T1 < T0
based teletreatment 40 ± 12.4 CG = 35 modality) 4 weeks total T1: week 4 EG = CG for T1
service in patients (35 women; CG = T2: 12 weeks
with non-specific 0 men) conventional Treatment time: Disability (PDI)
neck and shoulder treatment 60 minutes EG: T1* < T0
pain: A randomized (medication + CG: T1* < T0
controlled trial [55] physical therapy EG = CG for T1
+ chiropractic
+ osteopathy +
acupuncture)
61
Clinical Study Autor Musculoskeletal Sample size (n) EG and CG Intervention MF sessions and Evaluations Outcomes Conclusion 62
(years)
10 Effect of EMG Spence Cervicobrachialgia n = 48 EG 1 = 12 EG 1 = UT Sessions: T0: baseline Depression Depression (BDI)
biofeedback [1995] Men = 8 (NS) and EF MF 8 sessions (before (BDI) EG 1: T2 < T1 < T0
compared to applied England Women = 40 EG 2 = 12 EG 2 = UT (2 weekly treatment) Pain intensity EG 2: T2 < T1 < T0
relaxation training 42 ± 7.86 (NS) and EF MF sessions) – 4 T1: week 4 (end (PBQ) CG 1: T2* < T1* < T0
with chronic, CG 1 = 12 + relaxation weeks total of treatment) Pain CG 2: T1 > T0
upper extremity (NS) exercises T2: 24 weeks (WHYMPI) CG 1 < EG 1 < EG 2 < CG 2 for T2* and T1*
cumulative trauma CG 2 = 12 CG 1 = Treatment time: (follow-up) Stress caused Pain intensity (PBQ)
disorders [56] (NS) relaxation 90 minutes by pain (self- EG 1: T2 < T1 < T0
exercises monitored EG 2: T2 < T1 < T0
CG 2 = NT pain, distress, CG 1: T2 < T1 < T0
interference and CG 2: T1 > T0
medication) EG 1 < EG 2 < CG 1 < CG 2 for T2 and T1
Pain Pain (WHYMPI)
interference EG 1: T2 < T1 = T0
daily living EG 2: T2 < T1 = T0
activities CG 1: T2 < T1 = T0
(self-monitored CG 2: T1 > T0
pain, distress, EG 1 = EG 2 = CG 1= CG 2 for T2 and T1
interference and Stress caused by pain (self-monitored pain,
medication) distress, interference and medication)
EG 1: T2 < T1 < T0
EG 2: T2 < T1 < T0
CG 1: T2 < T1 < T0
CG 2: T1 > T0
EG 1 < EG 2 < CG 1 < CG 2 for T2* and T1*
Pain interference daily living activities
(self-monitored pain, distress, interference
and medication)
EG 1: T2 < T1 < T0
EG 2: T2 < T1 < T0
CG 1: T2* < T1* < T0
CG 2: T1 > T0
CG 1 < EG 1 < EG 2 < CG 2 for T2* and T1*
ALG, algometry; BDI, Beck Depression Inventory; CBT, cognitive behavioral therapy; CSQ, Coping Style Questionnaire; CG, control groups; COMP, Canadian Occupational Performance Measure;
COPSOQ, Copenhagen Psychosocial Questionnaire; DA, anterior deltoid muscle; DM, dynamometry; EG, experimental groups; EF, elbow flexors muscles; EMG, surface electromyography; IM, inclino-
meter; FIC, functional capacity index; GALS, general activity level scale; LBPS, low back pain syndrome; HP, hot packs; MPI-S, multidimensional Pain Inventory; NDI, the Neck disability Index; NPRS,
numeric pain rating scale; NS, not specified; NT, no treatment; PBQ, personality belief questionnaire; PDI, pain disability index; PPT, purdue perbog test; UE, upper extremities; UT, upper trapezius
muscle; ROM, range of movement; SE, spinal erectors muscles; STAI, State Trait Anxiety Inventory; TrPs, myofascial trigger points; TRH, telerehabilitation; TS, tender spots; TSK, TAMPA Scale for
Kinesiophobia; VAS, visu al analogue scale; WAI, Work Ability Index; WLC, waiting list controls; WHYMPI, West Haven-Yale Multidimensional Pain Inventory; WPS, whiplash syndrome; *p < 0.5.
Complementary treatments for muscle strengthen- treatment; T0, T1 and T2) (n = 8, 80.00%) [50–56],
ing MF included therapeutic exercises (stretching ex- while the strengthening studies documented mostly
ercises, resistance, mobility, coordination, propriocep- 2 evaluation sessions (before and after treatment; T0
tion or water exercises) (n = 14, 53.84%) [22,23,35–37, and T1) (n = 10, 62.50%) [23,35–37,30–43,45,47,48].
39,40,42–44,46–48] functional electrical stimulation On the other hand, Draper (1997) and Christanell
(FES) (n = 1, 6.25%) [45], neuromuscular electrical (2012) carried out 5 evaluation sessions for strengthen-
stimulation (NMES) (n = 2, 12.5%] [35,44], lymphatic ing MF (T0–T4) [38,44], while Atteya (2004) reported
drainage (n = 2, 12.5%) [22,44], hot packs (HP) (n = 1, 7 sessions for relaxation MF (T0–T6) [52]. An average
6.25%) [28] and cryotherapy (n = 1, 6.25%) [46]. On evaluation time of 1 week between sessions is high-
the other hand, complementary treatments for muscle lighted for both MF applications.
relaxation MF included cervical distraction (n = 1,
6.25%) [41], HP (n = 1, 6.25%) [41], relaxation tech- Main outcomes
niques (n = 1, 6.25%) [56] and therapeutic exercises
(stretching and functional exercises) (n = 2, 12.5%) Strengthening MF studies
[49,53]. Only Eslamian (2020) used NSAIDs in partici- The main outcomes of the strengthening MF stud-
pants with neck pain in addition to MF relaxation [53]. ies included functionality (disability) (n = 12, 75.0%)
The control groups in the strengthening MF stud- [22,23,40,42–46,48], pain intensity (n = 9, 56.25%)
ies received therapeutic exercises (resistance exercises, [22,23,35,40–44,47,48], gait speed (n = 1, 3.8%)
flexibility, functional and home exercises) [22,23, [22], range of motion (ROM) changes (n = 6, 37.5%)
35–38,40,42,46–48], NMES [22,38,43,44], FES [45], [22,36,38,42,44,46], decreased edema (n = 2, 12.5%)
superficial thermotherapy (HP) [50,52], TENS [41], US [22,44], changes in electromyographic activity (n=13,
[41], postoperative lymphatic drainage and water exer- 81.25%) [22,23,35,36,40–42,44–48], muscle strength
cises [44]. In addition, it should be noted that no articles changes (n = 7, 43.75%) [35,38,39,41,43,44,47], mus-
reported the use of drugs for CG. On the other hand, for cular thickness (n = 3, 18.75%) [41,46,48] and subjec-
CG in muscle relaxation MF studies, superficial ther- tive health assessment (n = 1, 0.06%) [42]. Functionality
motherapy (HP) [52], joint distraction [52], acupunc- was assessed with the Lyshom scale [22,46], the Knee
ture [53], therapeutic exercises (isometric exercises, injury and Osteoarthritis Outcome Score (KOOS) [46],
stretching and relaxation) [49,53,56], cognitive behav- the hand, arm and shoulder disability index (DASH)
ioral therapy (CBT) [54], joint manipulation [55], and [23], the Oxford shoulder scale (OSS) [23], function-
medication [53,55] were used. The studies by Dellve al capacity index (FCI) [40], 50-meter walk test (50-
(2011), Spence (2016) and Gálvez-Hernández (1995) WMT) [43], the Western Ontario and McMaster ques-
did not administer treatment for CG [25,50,56]. tionnaire (WOMAC) [42,43,48], the International Knee
Regarding the treatment sessions, an average of Documentation Committee (IKDC) guideline [44], the
5 sessions was observed for strengthening MF and 8 Oswestry Disability Index (ODI) [45] and Lequesne
sessions for relaxation MF. Minimum sessions for Index [48]. On the other hand, pain intensity was
strengthening MF studies were 1 (Huang, 2013) [36] evaluated with the visual analog scale (VAS) [22,40,
with a maximum of 30 (Kirnap, 2005) [46], while mini- 41–44,48], KOOS [35] and numerical pain rating score
mum sessions for muscle relaxation MF studies were (NPRS) [23,47], while gait speed was assessed with the
3 (Gálvez-Hernández, 2016) [25] with a maximum of 2-meter walk test (2-WMT) [22]. Electromyographic
16 (Dellve, 2011) [50]. Strengthening studies (n = 9, activity (EMG-A) was evaluated with surface electro-
56.25%) sessions were mostly carried out in continu- myography [23,35–37,40,44,45,47,48], while muscle
ous days in an average of 5 weeks [23,24,26,27,28,32, strength assessment was performed through dynamom-
34–36], while muscle relaxation MF studies (n = 9, etry [35,39,41,45,47], isokinetic assessment [38,42]
90.00%) included interval sessions averaging 5 weeks and maximum resistance estimation (Rmax) [43]. Mus-
[24,25,50–56]. cle thickness was examined by ultrasonography [41,48]
The average treatment time for strengthening MF and muscle circumference measurement [46], while pe-
was 20 to 30 minutes, with a minimum of 4 minutes rimetry was used to quantify edema [22,44]. Subjective
reported by Huang [36] and a maximum of 30 minutes health assessment was assessed with the Nottingham
[37,38,40,45], while the average treatment time for Health Profile (NHS) [42].
relaxation MF was between 40 and 50 minutes, with Results show an improvement in intragroup func-
a minimum of 5 minutes reported by Ehrenborg (2010) tionality for Lyshom, KOOS, OSS, DASH, IKDC, ODI,
[51], and a maximum of 120 minutes by Dellve [50]. WOMAC, and Lequesne index, although with statisti-
The review revealed, for most of relaxation MF cal significance in favor of EG (intergroup) for menis-
studies, 3 evaluation sessions (before and two after cal rehabilitation studies (Lyshom scale, p < 0.001)
[22,46], knee OA (50-WMT, p < 0.01; WOMAC, general activity level scale (GALS) [54]. Pain intensi-
p < 0.05) [42,43], and lumbar hernia (ODI, p < 0.0001) ty was assessed with NPRS [50], pain self-perception
[45]. MF applications focused on quadriceps femoris scale [24], pressure algometry (PA) [24,53], symptom
strengthening for knee conditions, and tibialis anterior checklist [24], VAS [25,53,55], pain beliefs personality
muscle in patients with low back pain. Likewise, a sta- questionnaire (PBQ) [54,56], pain self-report [54], and
tistically significant functionality improvement is seen West Haven Yale multidimensional inventory (WHYM-
for CG that received alternative treatment in meniscal PI) [56]. On the other hand, mental health was assessed
injuries [22,46], SAIS [23] and knee OA [42,43,48], through participants’ self-report [50], Beck’s depression
although they did not show to be better than MF treat- inventory (BDI) [24,25,54,56] and state-trait anxiety
ment. On the other hand, a decrease in pain is observed inventory (STAI) [54]. EMG-A, ROM and movement
in favor of EG for VAS, KOOS, and NPRS, although fear were evaluated using surface electromiography, in-
with statistical significance only for strengthening MF clinometry, and Tampa scale for kinesiophobia (TSK)
in meniscal injuries and OA (p <0.05) aimed at increas- respectively [25,52,53]. Finally, muscle strength and
ing quadriceps femoris strength (medial and lateral vas- health status were assessed through dynamometry and
tus) [22,41–43,48]. Gait speed shows an improvement the SF-36 health questionnaire [24,50].
in both groups between evaluation sessions, although Results show an improvement in functionality for EG
without significant differences [22]. EMG-A increased and CG, although with significance in favor of MF for
in both study groups, although with greater significance COMP (p < 0.01), MPI-S (p < 0.016), WAI (p < 0.01),
(p < 0.05) in EG when using strengthening MF in par- NDI (p < 0.01), and PDI (p < 0.03) in participants with
ticipants with meniscal injury [22,35,46,47], SAIS [36], cervicobrachialgia [49,55], neck pain [50,53] and WPS
PFPS [37], ACLR [44], and knee OA [48]. [51], in whom the aim was to reduce the activity of the
The main muscles trained in knee conditions were trapezius muscle. CG also shows an improvement in
quadriceps femoris, trapezius and anterior serratus in functionality (p < 0.05) between the evaluation sessions
SAIS. On the other hand, 4 studies evaluated muscle for the COMP, MPI-S, and WAI, although without be-
strength changes in patients with knee OA showing an ing better than MF [49–51]. A decrease in pain is ob-
increase in both groups, although with significant dif- served in EG for NPRS [50], VAS [25,53], PA [24,53],
ferences (p < 0.05) in favor of MF groups in which the PBQ [54], and pain self-report [54] in participants with
vastus medialis was trained [39,40,42,43]. On the other neck pain, fibromyalgia, LBPS, although without statisti-
hand, Choi reported an increase in vastus medialis thick- cal significance (p > 0.05). These studies show MF ap-
ness in patients with knee OA with significant changes plications in the upper trapezius for cervical conditions
compared to CG (p < 0.05) [41]. Regarding ROM, an and spinal erector for LBPS. Despite the above, Dellve
improvement is observed after MF treatment, although (2011) reported a greater decrease in pain in patients
with controversial results, reporting statistical signifi- with neck pain for one CG that did not receive treatment
cance by Akkaya, Christanell, and Kirnap [22,44,46], (p < 0.046) [50]. Mental health shows improvements for
and without differences between groups according to both study groups, although Spence (1995) reports sta-
Draper and Yilmaz [38,42]. Although the decrease in tistical significance in favor of controls for BDI in cervi-
edema was documented as a secondary outcome, only cobrachialgia (p < 0.01) [56]. EMG-A shows a decrease
Christanell reported its changes, showing a subjective in patients with cervical radiculopathy in favor of MF
reduction in patients with ACLR [44]. (p < 0.01) [52] and WPS (p < 0.046) [25]. On the other
hand, ROM increased for both groups in patients with
Muscle relaxation MF studies neck pain highlights (intragroup changes) (p < 0.001)
Main outcomes for muscle relaxation MF studies in- but without differences between them (p > 0.05). Finally,
cluded functionality (disability) changes (n = 8, 80.0%) movement fear, muscle strength and health state evalu-
[24,25,49–51,53–55], pain intensity decrease (n = 7, ated do not show statistically significant intra – or inter-
70.0%) [24,25,50,53–56], mental health improve group changes (p > 0.05) [24,50,51].
(n = 5, 50%) [24,25,50,54,56], EMG-A (n = 2, 20.0%)
[24,52], ROM changes (n = 1, 10.0%) [53], movement
fear (n = 1, 10.0%) [25], muscle strength changes [50] Discussion
and health state (n = 1, 10.0%) [24]. Functionality was
assessed with the Canadian Occupational Performance The objective of this SR was to investigate the sci-
Scale (COPM) [49,51], Psychosocial Functioning Scale entific evidence on the MF efficacy in function recov-
(MPI-S) [49,51], Work Ability Index (WAI) [50], Pur- ery, strength increase, and muscle relaxation in MSD.
due Pegboard Test (PPT) [26], FCI [24], ODI [25], neck Low risk of bias was assessed for most of the articles,
disability index [53], pain disability index [54,55] and showing only some concerns in the random assignment
domain for the RoB2 tool [22,23,37,39,40–51,53,55,56]. stabilizer scapular muscles while performing exercis-
PEDro score shows good internal validity for 17 studies es. Likewise, it is suggested, for muscular imbalance
(65.38%) supporting the methodology and results of the management, to first use relaxation MF in facilitated
analyzed articles [33]. muscles and later activation MF in inhibited muscles.
The studies were classified in two therapeutic ap- This review shows the MF application in the tibialis
plications: strengthening (n=16, 61.53%) and muscle anterior muscle reporting improvements in functional-
relaxation (n = 10, 38.46%). Both applications are in- ity in patients with LBPS [45]. Although this peripheral
teresting because they support MF’s ability to detect activation has not been clarified, facilitation of neuro-
subtle changes in motor neurons’ activity, often difficult logical circuits of lumbar spinal cord segments (L4-
to objectify with palpation or observation, in patients L5), responsible for motor control at the lumbar level,
treated to increase (strengthen) or decrease (relaxation) is recommended. Peripheral activation could facilitate
muscle activity. It should be noted that MF systems are lumbar spinal segments motor neurons, also associated
based on the information principle (Ross Ashby’s law), with lower back muscles so that an MF training could
in which a variable is correctly controlled (strength or result in lumbar muscles indirect activation.
relaxation) if the controller (patient) has enough infor- Strengthening MF offered increased functionality,
mation (visual and/or audible). decreased pain, increased ROM, and electromyographic
activity. Functionality was tested with different validated
Strengthening MF applications instruments which support stable, safe, and consistent
This review supports MF efficacy for strengthening results for strengthening MF therapy: Lyshom scales,
in knee OA, meniscal injury, SAISS, PFPS, ACLR, and test-retest (TRT) = 0.91 and internal consistency (IC)
lumbar discopathy when it is complemented with thera- = 0.65; KOOS, TRT=0.87-0.96 and IC = 0.78; DASH,
peutic exercises, FES, NMES, lymphatic drainage, and TRT = 0.97 and IC = 0.96; OSS, TRT = 0.82–0.91;
superficial thermotherapy showing greater benefits than ODI, TRT = 0.83-0.99 and IC = 0.71–0.87; WOMAC,
controls that received the same treatments, but without TRT = 0.83-0.90 and IC = 0.70–0.93 [60–64]. This re-
MF. MF applications focused on joint MSD that in- view shows an improvement in functionality, supporting
cluded knee conditions (n = 13) [22,23,37–44,46–48], the efficacy of strengthening MF in meniscal injuries,
shoulder (n = 2) [23,36] and lumbar spine (n = 1) [45]. SAIS, and knee OA. Although it is complex to explain
Knee conditions included postsurgical (n = 10) and non- a direct relationship between MF and functionality, these
surgical (n = 3) MF rehabilitation focusing on quadri- changes could be the result of the visual and auditory in-
ceps femoris strength recovery. Quadriceps femoris tegration, at different levels, of the CNS due to biofeed-
strengthening in these disorders is key due to muscle back, which allows patients to better control their motor
inhibition caused by pain and joint inflammation (ar- activity as occurs with daily life tasks in which motor
throgenic muscle inhibition, AMI). AMI results in an patterns are constantly fed back by the somatosensory
altered proprioceptive information decreasing quadri- and proprioceptive systems [65]. Functional improve-
ceps femoris strength, whose role is essential for lower ments can also be explained by the “pain-fear-disability”
limb functional activities [58]. circle interruption, a model that explains the close rela-
MF stimulates neural circuits, providing new soma- tionship between pain, its emotional factors, and conse-
tosensory information (visual and/or auditory) to mo- quent disability, and that would be modulated by visual
tor activities, recovering afferent and proprioceptive or auditive stimuli when the patient trains with MF [66].
information. Motor control is influenced by visual and Attention and concentration are factors that influ-
auditory systems through motor pathways modulation ence pain perception, involving the participation of
(corticospinal pathway) that regulates A-alpha motor descending modulatory mechanisms whose antinoci-
neurons. In this line, MF favors the activation of these ceptive effects may be equal to or better than those of
systems by modulating motor activity at different lev- morphine. This antinociceptive effect seem to be sup-
els of CNS [29,30]. On the other hand, shoulder and ported by the decrease in thalamocortical activity, thala-
LBPS treatments included MF training in trapezius mus, somatosensory areas, insula and anterior cingulate
and serratus anterior, and tibialis anterior respectively gyrus. The effect results in pain decrease perception
[23,36,45]. MF can recover scapulothoracic muscles when training with MF due to the patient’s lessened at-
strength, whose imbalances lead to scapular dysfunc- tention to the injury while concentrating on the visual
tions in addition to biomechanical alterations, such as and auditory stimuli.
decreased subacromial space and scapular upward [59]. Other analgesic mechanisms have supported en-
MF in shoulder rehabilitation protocols can be a valu- dogenous opioid peptides release with motor electrical
able resource to correct muscle imbalances by providing stimulation [68]. MF allows a simultaneous NMES with
patients with visual or auditory information to activate MVC configuration while feedback is generated, which
could favor endogenous opioids release when training self-regulation (previously explained). This improvement
with electrical currents; however, studies do not docu- can also be explained by the “information principle,” in
ment combined applications of MF and NMES. On the which the variable (muscle tone) is controlled when the
other hand, MF motor pathways (different levels), vi- person has information about it. On the other hand, self-
sual, and auditory cortex activation modulate muscle regulation of muscle tone added to concentration on the
tone by adjusting it to perform a certain motor activity, task while training with MF could explain the analgesic
interrupting the muscle spasm-pain circle (muscle tone effects, mediated by changes in attention [67].
self-regulation) [69]. It is interesting that some studies considered health
According to the results for strengthening MF, 15 to status, movement fear, and depression as secondary
20 sessions 3 to 5 times per week are recommended to outcomes, especially considering that MF showed ben-
ensure functionality improvements and muscle strength. efits in patients with fibromyalgia and LBPS. These
Although treatment times are varied, it seems that there results support the MF central modulation that could
are sufficient interventions between 15 and 30 minutes. exert an inhibitory effect at the limbic system, modi-
It should be noted that, for MF training development, fying psycho-affective response and pain perception of
the patient must be able to perform voluntary muscle the individual [12].
activity. This finding suggests that MF intervention for According to the results, 8 to 12 sessions 3 to 5 times
strengthening is more useful in MSD in which muscle per week are suggested to achieve favorable functional
function is preserved. In addition, it is important to ex- changes for relaxation with MF. Although the treatment
plain to patients that the equipment is not the one that im- times are varied, interventions between 30 and 60 min-
proves strength but only monitors their muscle activity. utes are recommended. Likewise, it should be consid-
ered that, due to prolonged treatment time, many clini-
Relaxation MF applications cians could opt for other relaxation strategies despite
Relaxation MF generally uses audible feedback the clear benefits and comparative advantages that MF
while monitoring motor neuron activity (μV), emitting therapy shows.
a sound stimulus when electromyographic activity ex-
ceeds a preset baseline activity level, ensuring that the
patient consciously inhibits their muscles. Despite the Conclusions
above, mixed biofeedback (visual and auditory) is seen
in MF relaxation studies. MF is a safe and non-invasive treatment used in re-
This review supports MF efficacy for muscle relax- habilitation for different MSD. This treatment can be
ation in neck pain, cervicobrachialgia, fibromyalgia, used for muscle strengthening (active method) or re-
and LBPS when it is complemented with cervical dis- laxation (passive method), although both techniques
traction, superficial thermotherapy, US, and therapeutic require muscle function indemnity.
exercises, showing better therapeutic effects than con- This SR shows that strengthening and relaxation MF
trols that received the same interventions without MF. applications are effective for improving the functional-
MF applications focused on non-specific MSP on ity and reducing pain in the short and long term for dif-
the cervical spine and lumbar spine. The applications ferent joint and soft tissue disorders, especially when
were on the trapezius muscle (upper portion) for cervi- complemented with therapeutic exercises or physical
cal conditions and spinal erectors for participants with agents. MF treatment shows good results in psycho-
LBPS. The trapezius muscle is usually facilitated or ap- affective variables such as movement fear and depres-
pears more active in neck pain conditions due to the fact sion, suggesting a modulating influence on the CNS.
that it is responsible for dysfunctional postural patterns Although it was not possible to perform a meta-analysis
such as superior cruciate syndrome. A similar phenom- of the studies due to their heterogeneity, these results
enon occurs with lumbar erectors that are facilitated in seem promising and promote MF in the rehabilitation
low back pain conditions and that lead to postural dys- protocols of the revised MSDs, as well as the develop-
functions, such as inferior crossed syndrome [70]. ment of new research on other musculoskeletal condi-
MF studies show improvements in functionality and tions not documented in this review.
pain decrease. Functionality was evaluated with vali- Despite the results, a common aspect for MF applica-
dated instruments, which supports results for relaxation tions is the time required to prepare the patient as well
MF studies: ODI, TRT = 0.83–0.99 and IC = 0.71–0.87; as the time needed to carry out the training, which could
NDI TRT = 0.50–0.98 and IC = 0.85; WAI TRT = 0.92 discourage its use despite its benefits. Likewise, this SR
and IC = 0.74 [71,72]. allowed the researchers to propose a dosage recommen-
Improvements in functionality can be explained by the dation for strengthening and relaxation with MF, which
“pain-fear-disability” circle interruption and muscle tone can be revised and considered for future research.
Funding for 1160 sequelae of 289 diseases and injuries 1990-

This research received no external funding. 2010: a systematic analysis for the Global Burden of
Disease Study 2010. Lancet. 2012; 380(9859): 2163–
Conflict of interests 96.
The authors have no conflict of interest to declare. 14. GBD 2017 Disease and Injury Incidence and Preva-
lence Collaborators. Global, regional, and national
incidence, prevalence, and years lived with disabili-
References ty for 354 diseases and injuries for 195 countries and
territories, 1990-2017: a systematic analysis for the
1. Hawker GA. The assessment of musculoskeletal pain. Global Burden of Disease Study 2017. Lancet. 2018;
Clin Exp Rheumatol. 2017; 35 Suppl 107(5): 8–12. 392(10159): 1789–858.
2. El-Tallawy SN, Nalamasu R, Salem GI, LeQuang 15. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gib-
JAK, Pergolizzi JV, Christo PJ. Management of mu- berd M, et al. What does best practice care for mu-
sculoskeletal pain: An update with emphasis on chro- sculoskeletal pain look like? Eleven consistent re-
nic musculoskeletal pain. Pain Ther. 2021; 10(1): commendations from high-quality clinical practice
181–209. guidelines: systematic review. Br J Sports Med. 2020;
3. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Da- 54(2): 79–86.
vies M, Hübscher M. Exercise for chronic musculo- 16. Abdel Shaheed C, Maher CG, Williams KA, Day R,
skeletal pain: A biopsychosocial approach. Musculo- McLachlan AJ. Efficacy, tolerability, and dose-depen-
skeletal Care. 2017; 15(4): 413–21. dent effects of opioid analgesics for low back pain:
4. Park PW, Dryer RD, Hegeman-Dingle R, Mardekian A systematic review and meta-analysis: A systematic
J, Zlateva G, Wolff GG, et al. Cost burden of chronic review and meta-analysis. JAMA Intern Med. 2016;
pain patients in a large integrated delivery system in 176(7): 958–68.
the United States. Pain Pract. 2015; 16(8): 1001–11. 17. Mercadante S, Arcuri E, Santoni A. Opioid-induced
5. Arendt-Nielsen L, Fernández-de-Las-Peñas C, Gra- tolerance and hyperalgesia. CNS Drugs. 2019; 33(10):
ven-Nielsen T. Basic aspects of musculoskeletal pain: 943–55.
from acute to chronic pain. J Man Manip Ther. 2011; 18. Lin I, Wiles LK, Waller R, Goucke R, Nagree Y, Gib-
19(4): 186–93. berd M, et al. Poor overall quality of clinical practice
6. Blyth FM, Noguchi N. Chronic musculoskeletal pain guidelines for musculoskeletal pain: a systematic re-
and its impact on older people. Best Pract Res Clin view. Br J Sports Med. 2018; 52(5): 337–43.
Rheumatol. 2017; 31(2): 160–8. 19. Beutler A. Musculoskeletal therapies: Adjunctive phy-
7. Jensen TS, Baron R, Haanpää M, Kalso E, Loeser JD, sical therapy. FP Essent. 2018; 470: 16–20.
Rice ASC, et al. A new definition of neuropathic pain. 20. Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nie-
Pain. 2011; 152(10): 2204–5. lens H. The efficacy of manual therapy and exercise
8. Szok D, Tajti J, Nyári A, Vécsei L. Therapeutic ap- for different stages of non-specific low back pain:
proaches for peripheral and central neuropathic pain. an update of systematic reviews. J Man Manip Ther.
Behav Neurol. 2019; 2019: 8685954. 2014; 22(2): 59–74.
9. van Griensven H, Schmid A, Trendafilova T, Low M. 21. Smith BE, Hendrick P, Bateman M, Holden S, Little-
Central sensitization in musculoskeletal pain: Lost in wood C, Smith TO, et al. Musculoskeletal pain and
translation? J Orthop Sports Phys Ther. 2020; 50(11): exercise-challenging existing paradigms and introdu-
592–6. cing new. Br J Sports Med. 2019; 53(14): 907–12.
10. Pelletier R, Higgins J, Bourbonnais D. Is neuroplasti- 22. Akkaya N, Ardic F, Ozgen M, Akkaya S, Sahin F, Ki-
city in the central nervous system the missing link to lic A. Efficacy of electromyographic biofeedback and
our understanding of chronic musculoskeletal disor- electrical stimulation following arthroscopic partial
ders? BMC Musculoskelet Disord. 2015; 16(1): 25. meniscectomy: a randomized controlled trial. Clin Re-
11. Baliki MN, Mansour AR, Baria AT, Apkarian AV. habil. 2012; 26(3): 224–36.
Functional reorganization of the default mode network 23. Juul-Kristensen B, Larsen CM, Eshoj H, Clemmensen
across chronic pain conditions. PLoS One. 2014; 9(9): T, Hansen A, Bo Jensen P, et al. Positive effects of neu-
e106133. romuscular shoulder exercises with or without EMG-
12. Fenton BW, Shih E, Zolton J. The neurobiology of pa- biofeedback, on pain and function in participants with
in perception in normal and persistent pain. Pain Ma- subacromial pain syndrome – A randomised controlled
nag. 2015; 5(4): 297–317. trial. J Electromyogr Kinesiol. 2019; 48: 161–8.
13. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud 24. Baumueller E, Winkelmann A, Irnich D, Weigl
C, Ezzati M, et al. Years lived with disability (YLDs) M. Electromyogram biofeedback in patients with
fibromyalgia: A randomized controlled trial. Comple- 38. Draper V, Ballard L. Electrical stimulation versus elec-
ment Med Res. 2017; 24(1): 33–9. tromyographic biofeedback in the recovery of quadri-
25. Gálvez-Hernández CL, Rodríguez-Ortiz MD, Del Río- ceps femoris muscle function following anterior cruci-
Portilla Y. Biofeedback treatment for acute whiplash ate ligament surgery. Phys Ther. 1991; 71(6): 455–61.
patients. Rev Med Inst Mex Seguro Soc. 2016; 54(4): 39. Anwer S, Quddus N, Miraj M, Equebal A. Effective-
480–9. ness of electromyographic biofeedback training on
26. Narayanan SP, Bharucha AE. A practical guide to bio- quadriceps muscle strength in osteoarthritis of knee.
feedback therapy for pelvic floor disorders. Curr Ga- Hong Kong Physiother J. 2011; 29(2): 86–93.
stroenterol Rep. 2019; 21(5): 21. 40. Dursun N, Dursun E, Kiliç Z. Electromyographic bio-
27. Dost Sürücü G, Tezen Ö. The effect of EMG biofeed- feedback-controlled exercise versus conservative care
back on lower extremity functions in hemiplegic pa- for patellofemoral pain syndrome. Arch Phys Med Re-
tients. Acta Neurol Belg. 2021; 121(1): 113–8. habil. 2001; 82(12): 1692–5.
28. Robinson AJ, Snyder-Mackler L, editors. Clinical 41. Choi YL, Kim BK, Hwang YP, Moon OK, Choi WS.
Electrophysiology: Electrotherapy and Electrophy- Effects of isometric exercise using biofeedback on
siologic Testing. 3rd ed. Philadelphia, PA: Lippincott maximum voluntary isometric contraction, pain, and
Williams and Wilkins; 2007. muscle thickness in patients with knee osteoarthritis. J
29. Avanzino L, Pelosin E, Vicario CM, Lagravinese G, Phys Ther Sci. 2015; 27(1): 149–53.
Abbruzzese G, Martino D. Time processing and motor 42. Yilmaz OO, Senocak O, Sahin E, Baydar M, Gulba-
control in movement disorders. Front Hum Neurosci. har S, Bircan C, et al. Efficacy of EMG-biofeedback
2016; 10: 631. in knee osteoarthritis. Rheumatol Int. 2010; 30(7):
30. Moher D, Liberati A, Tetzlaff J, Altman DG, PRI- 887–92.
SMA Group. Preferred reporting items for systematic 43. Durmuş D, Alayli G, Cantürk F. Effects of quadriceps
reviews and meta-analyses: the PRISMA statement. electrical stimulation program on clinical parameters
BMJ. 2009; 339: b2535. in the patients with knee osteoarthritis. Clin Rheuma-
31. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid tol. 2007; 26(5): 674–8.
A. Rayyan—a web and mobile app for systematic re- 44. Christanell F, Hoser C, Huber R, Fink C, Luomajoki
views. Syst Rev. 2016; 5(1). H. The influence of electromyographic biofeedback
32. Albanese E, Bütikofer L, Armijo-Olivo S, Ha C, Egger therapy on knee extension following anterior cruciate
M. Construct validity of the Physiotherapy Evidence ligament reconstruction: a randomized controlled tri-
Database (PEDro) quality scale for randomized trials: al. Sports Med Arthrosc Rehabil Ther Technol. 2012;
Item response theory and factor analyses. Res Synth 4(1): 41.
Methods. 2020; 11(2): 227–36. 45. Sardaru DP, Matei D, Zaharia-Kezdi D, Pendefunda L.
33. Sterne JAC, Savović J, Page MJ, Elbers RG, Blen- Effects of biofeedback versus switch-triggered func-
cowe NS, Boutron I, et al. RoB 2: a revised tool for tional electrical stimulation on sciatica-related foot
assessing risk of bias in randomised trials. BMJ. 2019; drop. J Back Musculoskelet Rehabil. 2018; 31(2):
366:l 4898. 239–45.
34. McGuinness LA, Higgins JPT. Risk-of-bias VISual- 46. Kirnap M, Calis M, Turgut AO, Halici M, Tuncel M.
ization (robvis): An R package and Shiny web app for The efficacy of EMG-biofeedback training on quad-
visualizing risk-of-bias assessments. Res Synth Meth- riceps muscle strength in patients after arthroscopic
ods. 2021; 12(1): 55–61. meniscectomy. N Z Med J. 2005; 118(1224): U1704.
35. Oravitan M, Avram C. The effectiveness of electro- 47. Levitt R, Deisinger JA, Remondet Wall J, Ford L, Cas-
myographic biofeedback as part of a meniscal repair sisi JE. EMG feedback-assisted postoperative rehabil-
rehabilitation programme. J Sports Sci Med. 2013; itation of minor arthroscopic knee surgeries. J Sports
12(3): 526–32. Med Phys Fitness. 1995; 35(3): 218–23.
36. Huang H-Y, Lin J-J, Guo YL, Wang WT-J, Chen Y-J. 48. Raeissadat SA, Rayegani SM, Sedighipour L,
EMG biofeedback effectiveness to alter muscle activ- Bossaghzade Z, Abdollahzadeh MH, Nikray R, et al.
ity pattern and scapular kinematics in subjects with The efficacy of electromyographic biofeedback on
and without shoulder impingement. J Electromyogr pain, function, and maximal thickness of vastus me-
Kinesiol. 2013; 23(1): 267–74. dialis oblique muscle in patients with knee osteoarthri-
37. Ng GYF, Zhang AQ, Li CK. Biofeedback exercise tis: a randomized clinical trial. J Pain Res. 2018; 11:
improved the EMG activity ratio of the medial and 2781–9.
lateral vasti muscles in subjects with patellofemoral 49. Ehrenborg C, Archenholtz B. Is surface EMG bio-
pain syndrome. J Electromyogr Kinesiol. 2008; 18(1): feedback an effective training method for persons
128–33. with neck and shoulder complaints after whiplash-
associated disorders concerning activities of daily ders of the knee. J Bone Joint Surg Am. 2004; 86(6):
living and pain – a randomized controlled trial. Clin 1139–45.
Rehabil. 2010; 24(8): 715–26. 61. Ebrahimi N, Jalaie S, Salsabili N, Ansari NN, Naghdi
50. Dellve L, Ahlstrom L, Jonsson A, Sandsjö L, Fors- S. Knee Injury and Osteoarthritis Outcome Score in
man M, Lindegård A, et al. Myofeedback training and patients with isolated meniscus injury; Validity and re-
intensive muscular strength training to decrease pain liability. J Res Med Sci. 2017; 22(1): 55.
and improve work ability among female workers on 62. Raven EEJ, Haverkamp D, Sierevelt IN, van Montfo-
long-term sick leave with neck pain: a randomized ort DO, Pöll RG, Blankevoort L, et al. Construct va-
controlled trial. Int Arch Occup Environ Health. 2011; lidity and reliability of the disability of arm, shoulder,
84(3): 335–46. and hand questionnaire for upper extremity complaints
51. Voerman GE, Vollenbroek-Hutten MMR, Hermens HJ. in rheumatoid arthritis. J Rheumatol. 2008; 35(12):
Changes in pain, disability, and muscle activation pat- 2334–8.
terns in chronic whiplash patients after ambulant my- 63. van der Linde JA, van Kampen DA, van Beers LWAH,
ofeedback training. Clin J Pain. 2006; 22(7): 6 56–63 van Deurzen DFP, Terwee CB, Willems WJ. The
52. Atteya AA. Biofeedback traction versus conventional Oxford Shoulder Instability Score; validation in Dutch
traction in cervical radiculopathy. Neurosciences (Riy- and first-time assessment of its smallest detectable
adh). 2004; 9(2): 91–3. change. J Orthop Surg Res. 2015; 10(1): 146.
53. Eslamian F, Jahanjoo F, Dolatkhah N, Pishgahi A, Pi- 64. Roos EM, Toksvig-Larsen S. Knee injury and Oste-
rani A. Relative effectiveness of electroacupuncture oarthritis Outcome Score (KOOS) – validation and
and biofeedback in the treatment of neck and upper comparison to the WOMAC in total knee replacement.
back myofascial pain: A randomized clinical trial. Health Qual Life Outcomes. 2003; 1(1): 17.
Arch Phys Med Rehabil. 2020; 101(5): 770–80. 65. Cano-de-la-Cuerda R, Molero-Sánchez A, Carratalá-
54. Newton-John TR, Spence SH, Schotte D. Cognitive- Tejada M, Alguacil-Diego IM, Molina-Rueda F, Mian-
behavioural therapy versus EMG biofeedback in the golarra-Page JC, et al. Teorías y modelos de control y
treatment of chronic low back pain. Behav Res Ther. aprendizaje motor. Aplicaciones clínicas en neurorre-
1995; 33(6): 691–7. habilitación. Neurologia. 2015; 30(1): 32–41.
55. Kosterink SM, Huis in ’t Veld RMHA, Cagnie B, Ha- 66. Zale EL, Lange KL, Fields SA, Ditre JW. The relation
senbring M, Vollenbroek-Hutten MMR. The clinical between pain-related fear and disability: a meta-analy-
effectiveness of a myofeedback-based teletreatment sis. J Pain. 2013; 14(10): 1019–30.
service in patients with non-specific neck and shoulder 67. Roy M, Lebuis A, Peretz I, Rainville P. The modula-
pain: a randomized controlled trial. J Telemed Teleca- tion of pain by attention and emotion: a dissociation
re. 2010; 16(6): 316–21. of perceptual and spinal nociceptive processes. Eur J
56. Spence SH, Sharpe L, Newton-John T, Champion D. Pain. 2011; 15(6): 641.e1-10.
Effect of EMG biofeedback compared to applied rela- 68. Bi Y, Wei Z, Kong Y, Hu L. Supraspinal neural mecha-
xation training with chronic, upper extremity cumula- nisms of the analgesic effect produced by transcuta-
tive trauma disorders. Pain. 1995; 63(2): 199–206. neous electrical nerve stimulation. Brain Struct Funct.
57. Stovold E, Beecher D, Foxlee R, Noel-Storr A. Study 2021; 226(1): 151–62.
flow diagrams in Cochrane systematic review updates: 69. Johnson DS. The spasm-pain-spasm cycle. Pain Med.
an adapted PRISMA flow diagram. Syst Rev. 2014; 2012; 13(4): 615.
3(1): 54. 70. Sembrano JN, Yson SC, Kanu OC, Braman JP, Santos
58. Sonnery-Cottet B, Saithna A, Quelard B, Daggett M, ERG, Harrison AK, et al. Neck-shoulder crossover:
Borade A, Ouanezar H, et al. Arthrogenic muscle inhi- how often do neck and shoulder pathology masquera-
bition after ACL reconstruction: a scoping review of de as each other? Am J Orthop (Belle Mead NJ). 2013;
the efficacy of interventions. Br J Sports Med. 2019; 42(9): E76-80.
53(5): 289–98. 71. MacDermid JC, Walton DM, Avery S, Blanchard A,
59. Struyf F, Nijs J, Mollekens S, Jeurissen I, Truijen S, Etruw E, McAlpine C, et al. Measurement properties
Mottram S, et al. Scapular-focused treatment in pa- of the neck disability index: a systematic review. J Or-
tients with shoulder impingement syndrome: a ran- thop Sports Phys Ther. 2009; 39(5): 400–17.
domized clinical trial. Clin Rheumatol. 2013; 32(1): 72. de Zwart BCH, Frings-Dresen MHW, van Duiven-
73–85. booden JC. Test-retest reliability of the Work Ability
60. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Index questionnaire. Occup Med (Lond). 2002; 52(4):
Hawkins RJ. Reliability, validity, and responsiveness 177–81.
of the Lysholm knee scale for various chondral disor-

2022 - RS Biofeedback para El Manejo de Dme

Uploaded by

Copyright:

Available Formats

You might also like

2022 - RS Biofeedback para El Manejo de Dme

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2022 - RS Biofeedback para El Manejo de Dme

Uploaded by

Copyright:

Available Formats

DOI: 10.5114/areh.2022.

Efficacy of biofeedback in rehabilitation of

Keywords: rehabilitation, biofeedback, musculoskeletal diseases, myofeedback,

Introduction depending on whether it persists for more than three

Records identified through database searching

Pubmed (n = 25); Scopus (n = 2918); Web of Science (n = 10); Cinahl (n = 1494);

Records after duplicates removed

• Outcome measures that (neurological conditions and

Fig. 1. Flowchart of included studies in accordance with PRISMA guidelines

Fig. 2. Risk of bias for the selected studies (ROBVIS tool)

Tab. 1. PEDro scale scores of analyzed studies

Clinical PEDro scale criteria

PEDro (Physiotherapy Evidence Database) scale criteria:

program (Phase 1: Edema (perimetry) Functionality (Lyshom scale)

participants rotation and KPP) + between each tilt (EMG) EG 2: T1 < T0

relaxation) VL MVC and AMVC (EMG)

CG: T1* < T0

Grip strength (DM)

Dexterity and gross movements

Self-reported mental health and

Beliefs about pain (PBQ)

General Activity Level (GALS)

Daily pain (self-report)

Funding for 1160 sequelae of 289 diseases and injuries 1990-

You might also like