Electromyography biofeedback therapy for spinal cord injury rehabilitation: a systematic review

Electromyographic biofeedback (EMG-BF) is being increasingly used as an adjunct to rehabilitation after spinal cord injury (SCI), but the available evidence is limited by the small sample size, heterogeneous comparators, and variable outcome reporting. We aimed to systematically identify and narratively synthesize the evidence on the effects of EMG-BF in SCI rehabilitation.

We searched the PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP and other databases from inception to 8 January 2026. Two reviewers independently screened records, extracted data and assessed the risk of bias using the Cochrane RoB 2 tool. Because of substantial clinical and methodological heterogeneity and inconsistent outcome-data types, we did not pool effect estimates; instead, we performed a structured synthesis without meta-analysis (SWiM) and graded the certainty of evidence using GRADE.

Ten randomized controlled trials (RCTs) involving 537 participants were included. All 10 studies reported a favorable direction of effect for EMG-BF, but the evidence for every outcome was of low or very low certainty. Across the five RCTs reporting surface electromyography (sEMG), all reported larger signal amplitudes in the EMG-BF arm, although the outcome data types varied (means vs. medians) and the muscle sites and comparators differed. Two RCTs reported greater lower-limb muscle strength with EMG-BF. One RCT reported a higher functional independence measure score, and two reported higher ASIA motor scores with the use of the EMG-BF. Four RCTs reported reduced spasticity (modified Ashworth scale, MAS), but MAS was reported inconsistently as ordinal grade distributions or as grade-derived scores, precluding any pooled estimate. Three RCTs reported higher Berg balance scale scores with the use of the EMG-BF. Only one pilot RCT reported pain, and it permitted only within-group comparisons.

Low- to very-low-certainty evidence suggests that EMG-BF may improve sEMG signals, lower-limb muscle strength, functional independence, ASIA motor scores, spasticity and balance in patients with SCI, but these findings are preliminary. Large, well-designed RCTs with allocation concealment, blinding of outcome assessors, standardized comparators and prospective registration are needed.

https://www.crd.york.ac.uk/PROSPERO/view/CRD420261282923, Identifier: [CRD420261282923].