ALFRED J. NIGL, Ph.D.

MARIELLA FISCHER-WILLIAMS, M.D.

Treatment of low back strainwith electromyographic bio­feedback and relaxation training

Dr. Nigl is chief psychologist and director of the biofeedback clinic. JacksonPsychiatric Center. Milwaukee. Dr. Fischer- Williams is a staff neurologist at St.Mary's Hospital. Milwaukee. Reprint requests 10 Dr. Nigl. 2130 North Mayfair Road.Milwaukee. WI 53226.

ABSTRACT: The authors examine the efficacy of electromyo­graphic (EMG) biofeedback and relaxation training for chroniclow back pain. Four case studies suggest that this combined treat­ment can lead to marked physical improvement, as evaluated bycomprehensive neurologic examination. The patients under studyexperienced significant reduction in muscular tension in theparalumbar area as well as substantial pain relief. After treat­ment the patients were either working or seeking employment.The authors conclude that EMG biofeedback can be an effectivetreatment for intractable pain.

For more than a decade, electro­myographic (EMG) biofeedbackhas been proving effective in cer­tain aspects of neurologic rehabili­tation. Disorders that have beentreated successfully includeparesis, I spasmodic torticollis,2 andfoot drop following stroke. 3 Re­cently, EMG training has beenused to decrease muscle contrac­tion in patients whose pain wasassociated with excessive muscleactivity. Although quantitativestudies have documented that the

muscle contraction of tensionheadache diminishes with EMGbiofeedback training,4 few re­searchers have investigated EMGtraining for pain in other anatomicareas such as, for example, thelumbosacral region.

Patients with pain from in­creased muscle contraction or fromchronic lumbosacral strain oftencannot obtain relief from standardmedical treatments, includingdrugs, injections of cortisone orlocal anesthetics, physical therapy

with local heat application, exer­cises, or ultrasound. For such pa­tients, EMG biofeedback trainingmay be successful in reducing in­tractable pain. Biofeedback differsfrom the treatment modalitiesmentioned above in that it providesthe patient with ongoing feedback(information in meaningful form)about his or her muscle contraction.The patient can thus monitor themuscle contraction frequency andintensity in relation to changes inposture, movement, and psycho­physiologic state, and thereby,theoretically, attain control of thecontractions.

An extensive survey of self-regu­lation treatment methods, includ­ing biofeedback, for chronic lowback pain showed that 50 of 72patients experienced a substantialreduction in pain.s Since biofeed­back training was only one of manytreatment techniques used in thisrehabilitation program, it is notclear just how effective the EMGtraining itself was. Another recentstudy demonstrated that differen­tial relaxation and EMG biofeed­back training were equally effective

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Biofeedback for back pain

FIGURE I-Average EMG values (Case I).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Follow-up

Treatment sessions

placed over the L5-S1 interspace, andthe average level of the patient's mus­cle activity was 51.22 microvolts (p.V)per minute, peak-to-peak. Prior to thefeedback training, she was instructedin a relaxation procedure involving vi­sualization of various muscles andmeditation (i.e., focused imagery8).

Outpatient biofeedback treatmentwas conducted for 18 one-hour ses­sions over a six-month period. Duringeach session the patient listened to acassette tape recording of the focusedimagery procedure and then at­tempted to reduce the auditory signalfrom the EMG biofeedback instru­ment. The patient's progress was alsomonitored during three additionalsessions (one per month) followingthe 18 treatment sessions. She waskept informed of her progress, receiv­ing copies of the EMG record sheetsfor each sessibn as reinforcement.

Results. The mean EMG readingsfor the baseline and treatment ses­sions are illustrated in Figure 1. Amarked decrease in the average levelof muscle tension was noted duringthe sixth session. Although the pa­tient's muscle potential averaged ap­proximately 50 p.V during the first ninetreatment sessions, the average forthe last nine sessions dropped to 17.7p.V. A sign test for correlated datashowed that this difference was sig­nificant (P<Ol). The average readingfor the three follow-up sessions was4.92 p.V, which is within normal limitsfor this area of the back. Pain wasassessed by the patient on a scalefrom 0 to 100, with 0 representing nopain and 100 representing maximumpain. She rated her pain level at 80during the first session and 20 duringthe follow-up sessions.

After the ninth session, the patientreturned to her job and graduallybegan to function at her former level.Prior to the last follow-up session, heremployer reported that her work ratewas more than satisfactory and thatshe no longer complained of pain.One year after the initiation of treat­ment, the patient was working and

Neurologic examination. Eightmonths after the injury, there was visi­ble and palpable spasm of the erectorspinae muscles, and the patient's gaitrevealed an exaggerated lumbar lor­dosis. Her lumbosacral movementswere limited, painful, slow, and stiff.Straight leg raising produced pain at a50° angle on the left but none at a 90°angle on the right. Local tendernesswas found at L5-S1 interspace withoutradiation of pain. Knee jerks were di­minished bilaterally, but ankle jerkswere present and symmetrical. Plan­tar responses were flexor. There wassensory impairment to light touch andto pinprick on the lateral border of theleft foot. The remainder of the neuro­logic examination yielded resultswithin normal limits. The electromyo­gram, the left common peroneal nerveconduction velocity, and the lumbarmyelogram were all normal.

Treatment. The patient was firstevaluated with an EMG biofeedbackinstrument at the time of the neuro­logic examination. Electrodes were

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Cas. 1A 35-year-old woman who was em­ployed in a laundry developed suddenlow back pain as she stooped overwhile trying to pull up a heavy objectfrom a laundry basket. At the time shewas referred for EMG biofeedback,she had not been working for ninemonths, and more than two months ofphysical therapy had provided no re­lief from the pain. The patient had nohistory of emotional problems.

in patients with chronic lumbar andparaspinal pain.6 However, anotherstudy suggested that the combina­tion of EMG biofeedback a"d im­agery-induced relaxation may bemore effective than either tech­nique alone.7

The cases discussed in this articleillustrate how treatment combiningEMG biofeedback and imagerytechniques can effectively reducesymptoms of chronic musculo­ligamentous low back strain.

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PSYCHOSOMATICS

Biofeedback for back pain

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Treatment sessions

FIGURE 2-Average EMG values (Cases 2.3. and 4).

Case 4A 44-year-old man was referred to usbecause of low back pain following aninjury caused by lifting a 250-lb deadcalf in the course of his work as aveal-farm manager. A second injuryoccurred three months later when hewas helping to hoist a Bengalliger in acage, causing a sudden, severe lowback pain. Two months after a courseof traction and physical therapy, thepatient experienced still more pain,this time while changing a motorpump. Although pelvic traction re­lieved the pain, a lumbar myelogramshowed an extradural defect on theleft at LS-S 1, and the patient had alumbar laminectomy for removal of aherniated L5-S1 disk. At discharge hewas reasonably comfortable, but therewas still some aching in the left leg.

Nine months later, an injury at workcaused a recurrence of pain. On ex­amination a month later, there wasvisible and palpable muscle spasm inthe lumbosacral paravertebral mus­cles, particularly on the left, with localtenderness. All movement of the lum-

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had increased significantly. He wasnot on medication, his morale wasmuch improved, and he was seekingemployment.

Case 3Another patient, a 34-year-oldwoman, was referred to us for "con­stant soreness" of the low back, par­ticularly on the left side, which she firstsuffered following a fall 15 monthspreviously. She had had only partialrelief from pain with physical therapyand the use of a back brace for severalmonths. On examination, there wastenderness of the paraspinal lumbo­sacral muscles, and movements of thelumbosacral spine were limited in alldirections. A diagnosis was made ofpost musculo-ligamentous low backstrain caused by injury. When re-ex­amined after three months of biofeed­back treatment, the patient was al­most free of pain and had returned toher job. Movements of the lumbosa­cral spine and of both hips had im­proved, and neurologic findings werewithin normal limits.

Additional case studiesAlthough these results suggestedthat biofeedback contributed to re­ducing the patient's physiologictension and its concomitant pain,since no control measure was em­ployed, we do not know whetherthe outcome was due to spurious,nonspecific factors. The same treat­ment was therefore given to threeother patients with conditions simi­lar to that of the first patient, in anattempt to replicate the results.These patients all had posttrau­matic low back strain that pre­vented their working. None had ahistory of psychiatric problems.

Case 2A 51-year-old man had a motorcycleaccident resulting in compressionfractures of T6 and T8 vertebrae.Three months later, he had a left-sidedstroke and was hospitalized for twomonths. Despite a good recovery,physical therapy, and his wearing aback brace for about seven months,low back pain persisted. He had leftfacial paresis and was comfortableonly in a semi-Fowler's position.

Following biofeedback treatment,his posture was greatly improved.Movements of the lumbosacral spinewere almost normal, and his activities

experiencing little lumbosacral ten­sion or pain.

Posttreatment examination. Severalweeks after the final treatment ses­sion, the patient showed marked im­provement in all aspects of neuro­muscular functioning: movements ofthe lumbosacral spine were painlessand almost full, motor power wasfunctional and symmetrical, tendonreflexes were present and symmetri­cal, and sensation was normal, as wasthe patient's gait. Straight leg taisingwas improved over results of the pre­treatment examination, although themovement still produced pain at a 70°angle on the left.

498 PSYCHOSOMATICS

bosacral spine was limited by pain andstiffness. Following two months ofbiofeedback treatment. the patient'smental and physical condition had im­proved. He was swimming twice aweek and preparing to return to work,but avoiding heavy lifting.

Treatment

Treatment for each of these threepatients included training in mus­cle relaxation (focused imagery)and EMG biofeedback during anaverage of 15 sessions. Electrodeswere placed over the area of per­ceived pain in the lumbosacral re­gion, and the treatment programgenerally followed the outlinegiven in Case I.

All three patients learned to re­duce their muscle tension signifi­cantly (P<.OI in each case). TheEMG results are illustrated in Fig­ure 2. In addition, daily analysis ofpatients' pain ratings indicated thatthe pain in all three patientsdropped substantially from thebaseline period to the final session.

DiscussionThese cases indicate that EMG

REFERENCES1. Basmajian JV: Biofeedback-Principles and

Practice for Clmicians. Baltimore. Williams &Wilkins. 1979.

2 Cleeland C: Biofeedback and other behavioralfechniques In treafment of dIsorders of volun­fary movement. in BasmaJian JV (ed) Biofeed­back-Pnnc/ples and Prac/lces for Clmic/ans.Baltimore. WIlliams & WilkIns. 1979.

3 Fernando CK. Basmallan JV: B,ofeedback In

JUNE 1980· VOL 21 • NO 6

biofeedback can effectively be usedto train individuals to reduce mus­cle contraction in the lumbosacralregion and thereby reduce theirpain from back injuries. We do notknow whether the patients wouldhave gradually learned to relaxtheir muscles over time withouttreatment. It is doubtful, however,that all four patients improved be­cause of nonspecific factors. In ad­dition, none of them was taking anymedication for pain or receivingany treatment except EMG bio­feedback and relaxation. Further­more, it is of interest that the pa­tients' pain subsided at a rate ap­proximating that of their increasedmuscular relaxation.

Because it provides "objective"information about physiologic re­sponses, biofeedback is a powerfullearning tool. Patients are hard putto deny that they are changingwhen they see changes on the EMGreadout. Biofeedback is also valu­able as a motivating vehicle forpatients who may have secondarygain, monetary or social, from theirdisability.

The patients discussed here all

the treatment of neuromuscular dIsordersB/ofeedback Sell Reguf3:450-460. 1978

4. BudzynskI T: Biofeedback procedures In theclinic. Seminars in Psychiatry 4:537-547.1973

5 Gottlieb H. Strite L. Koller R. et al: Comprehen­sive rehabIlitation ot patients havmg chroniclow back pam Arch Phys Med Rehabil58: 101­108. 1977

6. Nouwen A. Solinger J: Effectiveness of EMG

had poor self-images, and had con­vinced themselves that nothingwould help alleviate their intensepain, which (according to the re­sults of psychological tests) had asignificant psychological compo­nent. However, the success that allfour patients experienced in theinitial biofeedback session soongeneralized to other areas of theirlives. Their self-esteem improvedduring the course of the treatment,as evidenced by the results of theposttreatment psychological evalu­ations and by their attempts to findemployment rather than continueto depend upon receiving disabilityincome.

Further studies are needed toevaluate the part that may beplayed by suggestion or by othernonspecific factors in EMG bio­feedback. However, these cases, aswell as the results of Nouwen andSolinger's study,6 suggest thatEMG biofeedback, combined withrelaxation training, may be a usefuladjunct to traditional treatmentand rehabilitation of patients withchronic low back strain and asso­ciated pain.

bIofeedback trainIng ,n low back paIn. Bio­feedback Sell Reguf 4: 103-111. 1979

7. Nlgi A: Electromyograph feedback and aver­sive condItioning In treatment of chronic lowback paIn. In Proceedings of KyOfO SympoSiumon Biofeedback. Tokyo. SophIa UnIversityPress, 1980.

8 F,scher-WllIoams M, Nigl A, SovIne 0: A Text­book of Biological Feedback. New York,Human SCIences Press, to be published.

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