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Biofeedback for Constipation Dawn E 13 Biofeedback for Constipation Dawn E. Vickers Constipation, with its associated symptoms, is Biofeedback Defined the most common chronic gastrointestinal com- plaint, accounting for 2.5 million physician visits Schwartz et al9 define the biofeedback process as per year1 with a prevalence of 2% in the United “a group of therapeutic procedures which utilize States population.2 Rome II diagnostic criteria electronic instruments to accurately measure, for a diagnosis of constipation are specified in process, and feed back to persons and their ther- Table 13.1.3 After identification and exclusion of apists, meaningful physiological information extracolonic or anatomic causes, many patients with educational and reinforcing properties respond favorably to medical and dietary man- about their neuromuscular and autonomic activ- agement. However, patients unresponsive to ity, both normal and abnormal, in the form of simple treatment may require further physio- analog, binary, auditory and/or visual feedback logic investigation to evaluate the patho- signals.” This process helps patients develop a physiologic process underlying the symptoms. greater awareness of, confidence in, and an Physiologic investigation generally includes increase in voluntary control over physiologic colonic transit time study, cinedefecography, processes.This result is best achieved with a com- anorectal manometry, and electromyography petent biofeedback professional. Employing (EMG),4 which allows for definitive diagnosis of biofeedback instruments without proper cogni- treatable conditions including anismus, colonic tive preparation, instruction, and guidance is not inertia, rectocele, and sigmoidocele.5 appropriate biofeedback therapy. As with all Anismus, also termed pelvic floor dyssyner- forms of therapy, the therapist’s skill, personality gia, spastic pelvic floor syndrome, paradoxical and attention to the patient affect the outcome.9 puborectalis contraction, and nonrelaxing pub- It has been suggested that when researchers orectalis syndrome, accounts for an estimated understand the essential components of biofeed- 50% of patients with symptoms of chronic con- back training, research studies are often suc- stipation.6 Rome II diagnostic criteria for a diag- cessful. These components are as follows: (1) The nosis of pelvic floor dyssynergia are specified in biofeedback instrument is no more and no less Table 13.2.3 This disorder of unknown etiology than a mirror. Like a mirror, it feeds back infor- is characterized by failure of the puborectalis mation, but has no inherent power to create muscle to relax during defecation. Invasive sur- change in the user. (2) To maximize results, gical therapy or injection of botulinum neuro- biofeedback training, like any type of complex toxin7 are associated with an unacceptable skill training, involves clear goals, rewards for incidence of incontinence. In 1993, Enck’s8 criti- approximating the goals, ample time and prac- cal review found that biofeedback has become tice for achieving mastery, proper instruction, a widely accepted as the treatment of choice for variety of systematic training techniques, and anismus. feedback of information. (3) The individual 117 118 Constipation Table 13.1. Rome II criteria for diagnosis of constipation and the goals of training. A solid-state system is preferable to a water-perfused system because In the preceding 12 months, the patient had two or more of the following for 12 weeks, which need not be consecutive: there is no distraction or embarrassment from Straining >25% of defecations leakage of fluid, and the patient can be reori- Lumpy or hard stools >25% of defecations ented to a sitting position without adversely Sensation of incomplete evacuation >25% of defecations affecting calibration.Although this instrumenta- Sensation of anorectal obstruction/blockage >25% of defecations tion is of proven effectiveness, this method is Manual maneuvers to facilitate >25% of defecations (e.g., relatively cumbersome, complicated, and expen- digital evacuation, support of the pelvic floor) sive. The sEMG instrumentation is widely used, <3 defecations per week proven effective, and suitable for office use.11,12 Loose stools are not present, and there are insufficient criteria Patients are able to remain fully clothed during for irritable bowel syndrome the session and position changes are easily accomplished to assist with functional maneu- vers. The therapeutic component involves the using the feedback must have a cognitive under- clinician’s taking an active role by establishing a standing of the process and goals, and positive rapport with the patient, listening to concerns, expectations and positive interaction with the 10 reviewing the patient’s medical history including trainer, and must be motivated to learn. current medications as well as over-the-counter and herbal preparations, reviewing bowel and bladder habits, educating the patient, and inter- Practical Aspects of Biofeedback preting data. Therapy for Constipation Clinicians must have a complete unders- tanding of bowel and bladder functioning Practical aspects of using biofeedback therapy considering the coexistence of multifactorial for pelvic floor muscle (PFM) dysfunction to concomitant PFM dysfunction. In a patient with treat symptoms of constipation and fecal incon- symptoms of urinary stress incontinence, noc- tinence include the technical, therapeutic, turia, and difficulty voiding, Figure 13.1 shows behavioral, and the pelvic muscle rehabilitation the dysfunctional voiding pattern on the cys- (PMR) components. The technical component tometrogram (CMG).The increased sEMG activ- involves the instrumentation used to provide ity is indicative of outlet obstruction, inhibiting meaningful information or feedback to the user. the detrusor contraction, thus requiring exces- There are several technical systems available, sive straining by increasing intraabdominal and the advantages of any one device have not pressure to empty the bladder.This consequently been scientifically tested.Devices include surface produces a dysfunctional defecation pattern electromyography (sEMG), water-perfused and contributes to symptoms of constipation. manometry systems,and the solid-state manom- Chronic straining with stool is another source etry systems with a latex balloon. Although each of pelvic floor muscle denervation that contri- system has inherent advantages and disadvan- butes to pelvic floor muscle weakness and tages, most systems provide reproducible and useful measurements. The choice of any one system depends on many factors, including cost Increased EMG activity Table 13.2. Rome II diagnostic criteria for a diagnosis of pelvic floor Interrupted flow dyssynergia Detrusor Inhibition The patient must satisfy diagnostic criteria for functional constipation (Table 13.1) There must be manometric, EMG, or radiologic evidence for Increased vesical, abdominal & inappropriate contraction or failure to relax the pelvic floor urethral pressures muscles during repeated attempts to defecate There must be evidence of adequate propulsive forces during attempts to defecate, and There must be evidence of incomplete evacuation EMG, electromyography. Figure 13.1. Voiding phase cystometrogram (CMG) recording. Biofeedback for Constipation 119 incontinence.13 Patients with fecal incontinence response.9 As a behavioral program, the patient’s may complain of multiple daily bowel move- active participation is paramount in achieving ments and a feeling of incomplete evacuation subjective treatment goals, which include resulting in postdefecation seepage.9 Many symptom improvement, quality of life improve- patients who present with constipation fre- ment, and patient satisfaction. The PMR compo- quently have symptoms of urinary incontinence. nent involves designing an exercise program Due to the coexistence of concomitant multifac- suitable for each patient to achieve the ultimate torial PFM dysfunction associated with weak goal of efficient pelvic floor muscle function PFM and outlet obstruction, it is difficult to offer (Table 13.3). a specific standard biofeedback therapy protocol that is beneficial for all patients. Therefore, the clinician must address all bowel and bladder Surface Electromyography symptoms and develop an individualized Instrumentation program for each patient with progressive real- istic goals. The behavioral component is aimed There is no standardization for sEMG recordings toward systematic changes in the patient’s among manufacturers of biofeedback instru- behavior to influence bowel and bladder func- mentation; therefore, it is important for tion. Operant conditioning utilizing trial and clinicians to understand basic technical aspects error as an essential part of learning is merely such as signal detection, signal processing, data one aspect of the learning process. Treatment is acquisition, and display. aimed at shaping the patient’s responses toward a normal model by gradually modifying the patient’s responses through positive reinforce- Signal Detection ment of successive approximations to the ideal Surface electrodes summate the electrical action potentials from the contracting muscle and establish electrical pathways from skin contact Table 13.3. Exercise program suitable for each patient to achieve of the monitored muscle site (Fig. 13.2).9 The the ultimate goal of efficient pelvic floor muscle function: sEMG instrument receives and processes this components of pelvic muscle rehabilitation (PMR) utilizing surface electromyography (sEMG)
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