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 maneuvers. 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 understanding 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) instrumentation electrical correlate of a muscle activity measured µ sEMG instrumentation in microvolts ( V) (Fig. 13.3). Muscle contrac- Signal detection tion involves the pulling together of the two Signal processing anchor points; therefore, active electrodes Data acquisition and display should be placed between anchor points along sEMG evaluation the long axis of the muscle.9 The interelectrode Abdominal muscles Pelvic floor muscles distance determines the volume of muscle mon- Pelvic muscle exercise principles itored. Various types of electrodes are used with Overload sEMG devices for pelvic muscle rehabilitation. Specificity The most direct measure of the sEMG activity Maintenance from the pelvic musculature occurs when using Reversibility 14 Biofeedback treatment goals internal sensors. Binnie et al compared fine- Short-term wire electrodes to sensors with longitudinal Long-term electrodes and circumferential electrodes during Behavioral strategies rest, squeeze and push. Internal sensors with Patient education Dietary modification longitudinal electrodes correlated better with Habit training for difficult, infrequent, or incomplete evacuation fine-wire electrodes in all three categories (Fig. Urge suppression for urinary and fecal incontinence 13.4). Current internal sensors may detect one or Biofeedback-assisted pelvic muscle exercises two channels of sEMG activity. The two-channel Kegel exercises: isolated pelvic muscle contractions Beyond Kegel exercises: obturator and adductor assist multiple electrode probe (MEP) anal EMG Quick contractions sensor (Fig. 13.5) allows discrimination between Valsalva or push maneuver proximal and distal external anal sphincter Physiologic quieting techniques (EAS) activity, thereby allowing the clinician to Diaphragmatic breathing target specific areas of EAS inactivity in the Progressive relaxation techniques: hand warming rehabilitation process. 120 Constipation

Figure 13.4. The SenseRx internal vaginal and anal sensors with longitudinal electrodes that maintain proper orientation to muscle fiber for accurate EMG monitoring. (Courtesy of SRS Medical, Redmond, WA.)

musculature signal, the instrumentation should have a wide bandwidth filter of 30 to 500Hz. As Figure 13.2. Disposable surface electromyograph (EMG) electrodes. the muscle fatigues, a shift to the lower frequen- (From Vickers D, Davila GW. Kegels and biofeedback. In: Davila GW, Ghoniem GM, cies (Hz) occurs; therefore, a wide bandwidth Wexner SD, eds. Pelvic Floor Dysfunction: A Multidisciplinary Approach. London: Springer-Verlag, 2006:303–310.) allows signal detection of low-amplitude contractions.9 A 60Hz “notch” filter rejects power-line interference. As all electronic instru- Signal Processing mentation has internally generated noise, it is important for the clinician to know the internal The majority of the sEMG signal from the pelvic noise level in order to distinguish noise from the floor musculature is less than 100 hertz (Hz).The sEMG signal. instrumentation should have the ability to filter noise interference allowing for a clear signal to be displayed. To detect the majority of the pelvic

Figure 13.5. The multiple electrode probe (MEP) internal sensor. (Cour- Figure 13.3. The Orion platinum multimodality biofeedback system tesy of SRS Medical, Redmond, WA. From Vickers D, Davila GW. Kegels and biofeed- shows a typical display during a pelvic floor muscle (PFM) contraction. back. In: Davila GW, Ghoniem, GM, Wexner SD, eds. Pelvic Floor Dysfunction: A (Courtesy of SRS Medical, Redmond, WA.) Multidisciplinary Approach. London: Springer-Verlag, 2006:303–310.) Biofeedback for Constipation 121

Data Acquisition and Feedback Display Table 13.4. Abdominal and pelvic floor muscle surface electromyography (sEMG) evaluation The sEMG instrument is designed to separate sEMG resting baseline the electrical correlate of muscle activity from sEMG peak amplitude the contraction other extraneous noise and to convert this signal sEMG mean amplitude of the contraction during a 10-second period into forms of information or feedback meaning- < > 10 Duration of the contraction: 0 if 5sec, 1 if 5sec, 2 if 5sec and ful to the user. Adjusting the sensitivity settings ≤10sec, 3 if >10sec of the feedback display permits the clinician to sEMG muscle recruitment scale: 0, slow; 10, fast tailor the shaping process according to the Pelvic muscle isolation during contraction: 0, none; 10, good patient’s ability to perform an isolated pelvic Valsalva maneuver Progress this week: 0, worse, to 10, excellent muscle contraction. For example, if the sensitivity setting of the feedback display is 0 to 20 (µV), µ expanding the display to a scale of 0 to 10 ( V) Placing the active electrodes in the left and right provides reinforcement for submaximal con- anterolateral positions around the anal orifice tractions of weak muscles to help differentiate and placing the reference electrode on the gluteus between abdominal contractions. maximus or coccyx reduces artifact (Fig.13.6).To obtain an evaluation, instruct the patient to Surface Electromyography simply relax, then to perform an isolated pelvic muscle contraction over a 10-second period, fol- Evaluation lowed by performing a Valsalva maneuver; this sequence is repeated two to four times for accu- The abdominal and pelvic floor, the two channels racy (Table 13.4).During contraction,the abdom- of sEMG muscle activity, should be monitored inal muscle activity should remain relatively low simultaneously during the sEMG evaluation and and stable, indicating the patient’s ability to the sEMG biofeedback-assisted pelvic muscle isolate PFM contraction from abdominal con- exercise training. Interpretative problems arise traction (Fig. 13.7). During the Valsalva maneu- when monitoring only pelvic floor muscles ver, PFM muscle activity should decrease below without controlling changes in the intraa- the resting baseline to <2µV,while the abdominal bdominal pressure. The transmission of sEMG activity increases with elevated intraab- abdominal artifact to perennial measurements dominal pressure (Fig. 13.8). These objective invalidates changes in the pelvic floor muscle measurements are documented and reviewed measurements and can inadvertently reinforce with the patient. This also provides the clinician maladaptive abdominal contractions.9 The rec- with initial objective measurements to gauge ommended surface electrode placement for mon- training and recommended home practice itoring abdominal muscle activity is along the according to individual capabilities. long axis on the lower right quadrant of the abdominal oblique muscles. Perianal placement of surface electrodes may be used to monitor the Pelvic Muscle Exercise pelvic floor muscles when internal sensors are Training Principles inappropriate as in young pediatric patients. Training principles that are important in any exercise program include the overload principle, the specificity principle, and the maintenance Active @ 10 o’clock position principle. The overload principle states that, for pelvic muscles to strengthen, they must be exer- Active @ 4 o’clock position cised beyond their limit. If muscles are underex- ercised, they are not challenged enough to Reference @ coccyx or gluteal increase in strength, endurance, or speed; therefore, length and resting tone remains the con- stant. The specificity principle states that the Figure 13.6. Surface perianal placement (From Vickers D, Davila GW. Kegels and biofeedback. In: Davila GW, Ghoniem, GM, Wexner SD, eds. Pelvic Floor pelvic muscles are composed of fast- and slow- Dysfunction: A Multidisciplinary Approach. Springer-Verlag London Ltd, twitch fibers in roughly a 35% : 65% ratio; 2006:303–310.) some fibers have a combination of fast- and 122 Constipation

Figure 13.7. Channel 1: sEMG tracing of the PFM during contraction. Note the quick recruitment of appropriate PFM, ability to maintain the contraction, and ability to return to a normal resting tone. Channel 2: Abdominal sEMG tracing. Note the stability of the abdominal muscle activity. slow-twitch components. Fast-twitch fibers treatment plan with specific short-term and improve in speed and strength with quick con- long-term goals. Short-term goals describe the tractions, while slow-twitch fibers strengthen training components by which the patient may and gain optimal resting length and tone with achieve the functional changes, whereas long- longer “hold” contractions. Fast-twitch fibers term goals refer to the expected functional out- fatigue quickly while slow-twitch fibers are comes (Table 13.5).9 designed for endurance and postural tone; therefore, repetitions are low for fast-twitch fibers and higher for slow-twitch fibers. The maintenance Behavioral Strategies principle describes exercising for continence as a lifelong endeavor. The pelvic muscle strength Patient Education and is maintained by one daily 7- to 10-minute Behavior Modification session. The reversibility principle states that, after exercising and symptomatic improvement, Many misconceptions can be dispelled as discontinuing exercises will result in symptom patients gain a better understanding of their dis- reoccurrence over time.15 order. This education begins with reviewing the anatomy of the pelvic floor musculature and dis- cussing normal bowel and bladder function with Biofeedback Treatment Goals the use of visual aids. This exchange is followed by reassurance that irregular bowel habits and After identifying functional problems and sEMG other defecatory symptoms are common in the abnormalities, the clinician should prepare a healthy general population. Patients may exhibit Biofeedback for Constipation 123

Figure 13.8. Channel 1: sEMG tracing of the PFM during a Valsalva maneuver.Note the decreased muscle activity.Channel 2: Abdominal sEMG tracing.

a variety of behavioral patterns. Some patients Table 13.5. Surface electromyography pelvic muscle rehabilitation feel they need to have daily bowel movements treatment goals and resort to laxative and enema misuse. Some Short–term goals patients may make several daily attempts strain- Reinforce pelvic floor muscle contractions isolated from ing to evacuate, while others may postpone the abdominal and gluteal contraction urge or make hurried attempts for convenience. Reinforce pelvic floor muscle contractions toward greater amplitude and duration to improve strength and tone Another frequently observed behavioral pattern, Improve the coordination of pelvic floor muscle by shaping common among elderly women with symptoms pelvic floor muscle contractions with short repose latency of urinary incontinence,is the restriction of fluid and immediate recovery to baseline after voluntary intake to avoid leakage; in fact, this may worsen contraction ceases symptoms of constipation as well as symptoms Reduce chronically elevated pelvic floor muscle activity if implicated in perineal muscle pain, voiding dysfunction, or of urinary incontinence. Reviewing a daily associated bowel disorders record of bowel habits guides the clinician to Reduce straining pattern by reinforcing pelvic floor relaxation tailor education specifically to the underlying during defecation or micturation functional disorder. To generalize skills learned in the office to the home situation Long–term goals Decrease laxative, enema, or suppository use Increase number of spontaneous bowel movements Habit Training Decrease frequency of incontinent episodes Improved symptoms of incomplete evacuation Habit training is recommended for patients with Decreased straining symptoms of incomplete, difficult, or infrequent 124 Constipation evacuation. Patients are encouraged to set aside the genital muscles. He was instrumental in 10 to 15 minutes at approximately the same time developing a standardized program for treating each day for unhurried attempts to evacuate. The urinary stress incontinence. Kegel’s program patient should not be overly concerned with any included evaluation and training utilizing visual failure as another attempt later in the day is feedback for patients to receive positive rein- acceptable. This session is best initiated after a forcement as they monitored improvements in meal, which stimulates the gastrocolic reflex.16 the pressure readings. Kegel also recommended The majority of commodes are approximately structured home practice with the perineometer 35 to 40cm in height; if a patient’s feet or legs along with symptom diaries. His clinical use of hang free or dangle above the floor while sitting, these techniques showed that muscle reeduca- simulation of the squatting position will not be tion and resistive exercises guided by sight sense accomplished.Flexion of the hips and pelvis pro- are a simple and practical means of restoring vides the optimal body posture. Full flexion of tone and function of the pelvic musculature.17 the hips stretches the anal canal in an antero- Unfortunately, clinicians taught Kegel exer- posterior direction and tends to open the cises without the use of instrumentation. Bump anorectal angle, which facilitates rectal empty- et al18 showed that verbal or written instructions ing. This position may be achieved by the use of alone are not adequate, concluding that 50% of a footstool to elevate the legs and flex the hips.16 patients performed Kegel exercises incorrectly. Patients who have difficulty evacuating do There are disadvantages to teaching Kegel not tolerate the symptoms of gas and bloating exercises without specific feedback from muscle associated with fiber intake. Once emptying contractions. There is a strong tendency to sub- improves, these patients are encouraged to stitute abdominal and gluteal contractions for slowly begin weaning their laxative use and weak pelvic floor muscles. This incorrect slowly adding fiber. manner of performing Kegel exercises is rein- forced by sensory proprioceptive sensations, giving faulty feedback for the desired contrac- Dietary Modification tion, and, in effect, rendering the Kegel exercise useless.9 For patients with fecal or urinary incon- Dietary information is reviewed with all patients tinence, abdominal contractions raise intra- to assist in improving bowel function. Patients abdominal pressure, thereby increasing the are provided with written informational hand- probability of an accident. For patients to begin outs regarding foods that are high in fiber or performing isolated pelvic muscle contractions, foods that stimulate or slow transit. Offering they are instructed to contract their pelvic floor creative fiber alternatives, which may be more muscles without contracting abdominal, gluteal, appealing for patients to easily incorporate in or leg muscles, and to hold this contraction to their daily diet regimen, assists with compliance. the best of their ability. This is done while using Such alternatives include unrefined wheat bran the instrumentation display of the simultaneous that can be easily mixed with a variety of foods, sEMG activity of the abdominal and pelvic floor cereals, muffins, as well as over-the-counter muscles for feedback. The patient must tighten bulking agents. Adequate fluid intake and limit- the pelvic diaphragm (levator ani) in a manner ing caffeine intake is essential for normal bowel similar to stopping the passage of gas or the flow and bladder function; therefore, patients are of urine. Patients should be advised that the encouraged to increase their fluid intake to 64 initial aim of treatment is not to produce a con- ounces per day unless otherwise prescribed by traction of maximum amplitude, but to contract their physician. the pelvic floor muscle in isolation from other muscles without undue effort. To build muscle endurance, training proceeds with gradual Pelvic Muscle Exercise increases in the duration of each contraction along with gradual increases in the number of Kegel Exercises repetitions. Rhythmic breathing patterns during contractions should be encouraged. In the late 1940s, Arnold Kegel17 developed a Recommended home practice is tailored vaginal balloon perineometer to teach pelvic according to the patient’s ability and the degree muscle exercises for poor tone and function of of muscle fatigue observed during the session. Biofeedback for Constipation 125

At each stage of treatment, patients are encouraged to practice these exercises daily without instrumentation feedback. While Kegel17 asked patients to perform approximately 300 contractions daily during treatment and 100 during maintenance, there is no known optimal specific number of exercise sets. The goal of Kegel exercises is to facilitate rehabilitation of the pelvic floor muscles to achieve efficient muscle function. This includes normal resting tone, rapid recruitment of the pelvic floor muscles, sus- tained isolated pelvic muscle contraction, quick release to a normalized resting tone, and appropriate relaxation during defecation or micturation.

Beyond Kegels

The Beyond Kegel, a complete rehabilitation program for pelvic muscle dysfunction developed by Hulme, is based on the principle that the support system for the pelvic organs includes more than just the pelvic floor muscles. This support system, which is called the pelvic muscle Figure 13.9. Beyond Kegel obturator assist resistive exercise. force field (PMFF), includes the obturator internus, pelvic diaphragm (levator ani), urogenital diaphragm, and adductor muscles. In summary, these muscles function as an interdigitated and interrelated synergistic unit, rather than sepa- rated entities, to support abdominal organs, sta- bilize the lumbopelvic and sacroiliac region, and reflexively act for continence. Thus, as the obturator internus muscle contracts, it acts as a pulley, lifting the pelvic diaphragm and facilitat- ing closure of the urogenital diaphragm. As the adductor contracts, it lifts the pelvic diaphragm through overflow (proprioceptive neuromuscular facilitation) principles via the close approxi- mation of their attachments on the symphysis pubis. The balance and work/rest cycle of the obturator and adductor muscles function as an integral part of the urogenital continence system to maintain bladder and bowel continence and to facilitate effective and efficient elimination. One portion of the Beyond Kegel protocol includes resistive exercises: (1) Obturator assist: Roll knees out against an elastic band and hold for a count of 10 seconds. Release for a count of 10 seconds. Practice 10 repetitions three times Figure 13.10. Beyond Kegel adductor assist resistive exercise. daily (Fig. 13.9). (2) Adductor assist: Roll knees inward on a soft ball and hold for a count of 10 seconds. Release for a count of 10 seconds. Prac- tice 10 repetitions three times daily (Fig. 13.10). 126 Constipation

This is a simple and effective beginning exer- accomplish lowering sympathetic nervous cise for patients who are unable to perform system tone, promoting quiet emotions and isolated pelvic muscle contractions.As the pelvic relaxed muscles, and ultimately promoting a muscles become more efficient, patients can quiet body.20 progress to performing pelvic muscle contractions during the obturator assist and adductor assist 10-second hold. The Beyond Kegel proto- Anorectal Coordination Maneuver cols provide a detailed progressive pelvic muscle rehabilitation exercise program that has been Patients with symptoms of difficult, infrequent, shown to significantly improve and expedite the or incomplete evacuation or those individuals pelvic muscle rehabilitation process to achieve with increased muscle activity while performing efficient muscle function.15 the Valsalva maneuver during the initial evaluation are taught the anorectal coordination maneuver. The goal is to produce a coordinated Quick Contract and Relax Exercises movement that consists of increasing intraabdominal (intrarectal) pressure while simultane- This exercise improves the strength and function ously relaxing the pelvic muscles. During the of the fast-twitch muscle fibers primarily of the initial sEMG evaluation of the Valsalva maneu- urogenital diaphragm and external sphincter ver, patients are asked to bear down or strain as muscles. These fast-twitch muscle fibers are if attempting to evacuate, which may elicit an important for preventing accidents caused by immediate pelvic muscle contraction and increased intraabdominal pressure exerted closure of the anorectal outlet (Fig. 13.11). This during lifting, pulling, coughing, or sneezing. correlates with symptoms of constipation Once patients have learned to perform isolated including excessive straining and incomplete pelvic muscle exercises, they are instructed to evacuation. The results of the sEMG activity perform quick contract and release repetitions observed on the screen display must first be five to 10 times at the beginning and end of each explained and understood by the patient before exercise session they practice at home.15 awareness and change can occur. Change begins with educating the patient on diaphragmatic breathing, proper positioning, and habit train- Diaphragmatic Breathing ing. Relaxation and quieting the muscle activity Physiological Quieting while observing the screen is reviewed. Initially patients are instructed to practice these behav- The breathing cycle is intimately connected to ioral strategies; however, some patients may con- both sympathetic and parasympathetic action of tinue to feel the need to “push” or strain to assist the autonomic nervous system.19 Bowel and with expulsion. While observing the sEMG bladder function is also mediated by the muscle activity on the screen, they are instructed autonomic nervous system.10 Conscious deep to slowly inhale deeply while protruding the diaphragmatic breathing is one of the best ways abdominal muscles to increase the intraabdom- to quiet the autonomic nervous system. This inal pressure. They are then asked to exhale breathing effectively initiates a cascade of vis- slowly through pursed lips. The degree of the ceral relaxation responses. The aim of this exer- abdominal and anal effort is titrated to achieve cise is to make the shift from thoracic breathing a coordinated relaxation of the pelvic floor to abdominal breathing.19 Patients are instructed muscles. Patients are encouraged to reproduce to slowly inhale through the nose while pro- this maneuver during defecation attempts. truding the abdomen outward as if the abdomen is a balloon being inflated or allowing the abdomen to rise. This maneuver is followed by Biofeedback Sessions slow exhalation through the mouth as the abdominal balloon deflates or as the abdomen The initial session at the Cleveland Clinic– falls. Patients are encouraged to practice this in Florida begins with a thorough history intake. a slow, rhythmical fashion. Visualization and The learning process begins with a description progressive relaxation techniques in conjunction of the anatomy and physiology of the bowel and with diaphragmatic breathing may be used to pelvic muscle function using anatomic diagrams Biofeedback for Constipation 127

Figure 13.11. Channel 1: sEMG tracing of the PFM during a Valsalva maneuver. Note the increase muscle activity indicative of a paradoxical contraction. Channel 2: Abdominal sEMG tracing. and visual aids. Verbal and written instructions standing while reviewing urge suppression or are simplified for easy comprehension using sitting while performing the Valsalva maneuver. layman’s terminology. This is followed by a Surface electrodes are then placed on the right description of the biofeedback process, instru- abdominal quadrant along the long axis of the mentation, and PMR exercises. Patients should oblique muscles, below the umbilicus used to be aware that physicians cannot make muscles monitor abdominal accessory muscle use. The stronger or change muscle behavior. However, cables are attached to the SRS Orion PC/12 (SRS patients can learn to improve symptoms and Medical Systems, Inc., Redmond, WA) multi- quality of life by active participation and com- modality instrumentation that provides the mitment to making changes. Results are not ability to simultaneously monitor up to four immediate; as with any exercise program,muscle muscle sites (Fig. 13.3). The EMG specifications improvement requires time and effort. Begin- include a bandwidth of 20 to 500Hz and a 50/60- ning goals of isolated pelvic muscle contractions Hz notch filter. The sEMG evaluation is per- are established and an example of sEMG tracing formed and reviewed with the patient. showing efficient muscle function is reviewed. Training for dyssynergia, incontinence, or Patients are given instructions on proper inser- pain begins with the systematic shaping of iso- tion of the internal sensor and remain fully lated pelvic muscle contractions. Observation of clothed during the session. They are placed in a other accessory muscle use such as the gluteal or comfortable semi-recumbent position for train- thighs during the session is discussed with the ing; however, internal sensors work in a variety patient. Excessive pelvic muscle activity with an of positions for functional maneuvers such as elevated resting tone >2µV may be associated 128 Constipation

Figure 13.12. Channel 1: PFM sEMG tracing indicative of poor muscle function as seen with the slow recruitment, inability to maintain the contraction along with the recruitment of abdominal muscles seen in channel 2.

with dyssynergia, voiding dysfunction, and Multifactorial concomitant PFM dysfunction pelvic pain. Jacobson’s progressive muscle accounts for the rationale to initiate all patients relaxation strategy indicated that after a muscle with isolated pelvic muscle rehabilitative exer- tenses, it automatically relaxes more deeply cises. Home practice recommendations depend when released.21 This strategy is used to assist on the observed decay in the duration of the con- with hypertonia, placing emphasis on awareness traction accompanied by the abdominal muscle of decreased muscle activity viewed on the recruitment (Fig. 13.12). The number of con- screen as the PFM becomes more relaxed. This tractions the patient is able to perform before repetitive contract–relax sequence of isolated notable muscle fatigue occurs gauges the pelvic muscle contractions also facilitates dis- number of repetitions recommended at one crimination between muscle tension and muscle time. Fatigue can be observed in as few as three relaxation. Some patients, usually women, have a to four contractions seen in patients with weak greater PFM descent with straining during pelvic floor muscles. As an example of home defecation associated with difficulty in rectal practice, the patient performs an isolated pelvic expulsion. Pelvic floor weakness may result in floor muscle contraction, holds for a 5-second intrarectal mucosal intussusception or rectal duration, relaxes for 10 seconds, and repeats prolapse, which contributes to symptoms of con- three to 10 times (one set). One set is performed stipation. Furthermore, the PFM may not have three to five times daily, at designated intervals, the ability to provide the resistance necessary for allowing for extended rest periods between sets. extrusion of solid stool through the anal canal.16 The lower the number of repetitions, the more Biofeedback for Constipation 129 frequently interval sets should be performed tomized for each patient depending on the com- daily. Excessive repetitions may overly fatigue plexity of the functional disorder as well as the the muscle and exacerbate symptoms. If patients patient’s ability to learn and master a new skill. are unable to perform an isolated contraction on They are commonly scheduled from 1- to 1.5- the initial evaluation, they are given instructions hour visits once or twice weekly. Additionally, for the Beyond Kegel exercises. The goal for periodic reinforcement is recommended to patients is to be able to perform isolated pelvic improve long-term outcome.21 muscle contractions alternating with the Beyond Kegel exercises, to ultimately achieve efficient PFM function. All patients are requested to Adjunctive Treatment Method: keep a daily diary of bowel habits, laxative, enema or suppository use, fluid intake, number Balloon Expulsion of home exercises completed, fiber intake, and any associated symptoms of constipation or Various adjunctive biofeedback treatment incontinence. methods have been employed throughout the Subsequent sessions begin with a diary review years. Balloon expulsion has been used as an and establishing further goals aimed toward objective diagnostic tool and reportedly individualized symptom improvement. This is enhances sensory awareness in patients with followed by an sEMG evaluation, which may outlet obstruction. This training technique include the addition of quick contract and involves inserting a balloon into the rectum and release repetitions, Valsalva maneuver, or inflating with 50mL of air so that the patient has Beyond Kegel exercises depending on the the sensation of the need to defecate. Adherent patient’s progress. These objective measure- perianal placement of surface electrodes allows ments gauge improvements in muscle activity the patient to see the resultant sEMG pattern that should be seen with each visit and occur made by voluntary sphincter contraction. The prior to symptomatic improvement; this pro- patient is then asked to expel the balloon and if vides positive reinforcement for the patient to there is increased, rather than decreased, sphincter activity, the patient is instructed on straining continue treatment. To assist with compliance, 22 additional tasks should be limited to no more without increasing sphincter activity. than three at any given time. These tasks, tailored to the individual needs, may include increasing the duration and number of PFM Efficacy of Biofeedback: Literature Review exercises, alternating Beyond Kegel exercises, habit training, physiologic quieting, anorectal When interpreting the clinical outcome of the coordination maneuvers, increasing fiber and studies listed in Table 13.6, one should keep in fluid intake, increasing activity, or modifying mind that there are no established guidelines laxative use or other methods of evacuatory regarding the number of sessions, teaching assistance. Although the ideal goal may be to methods, clinician qualifications, type of abolish all symptoms, this may not always be equipment used, patient inclusion criteria, or accomplished due to underlying conditions; subjective or objective data used to establish however, individual goals are important, and success—all of which vary considerably. Hyman some patients may be satisfied simply with the et al’s23 critical review reports that, perhaps most ability to leave home without fear of a significant importantly, there is no identified standard for fecal accident. Improved quality of life and training biofeedback clinicians to treat pelvic patient satisfaction should be considered a treat- floor disorders. As with any therapy, the com- ment success. petence of the clinician is likely to have a significant impact on the outcome of treatment. Norton and Kamm24 report that many patients Session Duration and Frequency lack the motivation or are unconvinced about the possible value of what they perceive to At the onset of biofeedback therapy, it may be be simple exercises; therefore, the results of difficult to ascertain how many sessions are treatment are largely patient dependent, required for successful training. The number of unlike drug or surgical therapy. Gilliland et al25 biofeedback training sessions should be cus- reported that patient motivation and willingness 130 Constipation 2/wk roved rectal emptying reflex of external anal sphincterof external > improved vs not (29% vs 7%) @ 6 mo EMG endurance and net strength EMG endurance and net strength Frequency of spontaneous BM Frequency 3BM/week (27 vs 9) reduction 50% symptom % Anal relaxation Intrarectal pressure index Defecation BE time use Laxative Straining efined Success > > < Rectal mucosal blood flow: > > > > < < < completed completed therapy improved D BE 30% Symptom improvement 3 unassisted BM 3 unassisted pts completed y 58% Symptom improvement > autonomic functionautonomic testing or suppository (34 vs 9) Laxative transit (22 vs 9) Slow ( per wk) therapy) uestionnaire 43% Imp EMG MN, BE 2mo Diary 92% < Follow-up assessment 10wk 75% pts. < (2–9) 7mo Diary 80% Symptom improvement 2 6mo Diary 54.5% Symptom improvement BD 6 6mo Interview 12.5% BD 4–7 28mo Diary, rectal Laser 59% vs Postbiofeedback: Pre- MN 1–2/wk, 6mo Diar + + MN 3–4 12mo Diary, Mean Feedback Evaluation Percent IC 40 EMG 4–5 23mo Phone interview 57% improvement Symptom + flowmetry cardiorespiratory strain (26 vs 9) Need to rectal laser Doppler Doppler, BE, CTT EMG, MN Preevaluation DX age method Sessions MN, CTT, DF, AUS 7 CTT, DF, BE, MN PPC 30 NR 10 NR MN NR Effects inhibitory rectocolonic 49 BE, EMG, CTT, CRAFT, IC 39 EMG 11 CTT, MN, DF, EMG PPC30 DF, CTT, BEN, Colo, 43 PPC MN 19 MN, DF, CTT, EMG, BE 35 26 IC MN, DF, CTT, EMG, BE PPC 6332 55 EMG, DF, CTT, BE EMG EMG, PPC17 5025 EMG,DF, MN, CTT MN, EMG DF, CTT, BE PPC 4630 EMG, BE 50 4 MN, BE 8 2–10 14mo 65.3 Q EMG 5–11 No Diary 84% n 173 DF PPC 67 EMG116 EMG, DF194 EMG, DF, MN 4–7 IC PPC 4–7 73 71 Diary EMG EMG 55% 8 (2–14) 11 (5–30) 72mo normal Return to function bowel Improved Diary (63% 35% overall habits Normal bowel 73% Satisfaction rate 22 40 34 39 42 25 Biofeedback studies in constipation 36 29 31 37 41 35 38 30 1998 Lau 2000 1997 Patankar Emmanuel 2001 McKee 1999 McKee Rao 1997 Table 13.6. Table Author Rieger 1997 Mollen 1999 Gilliland 1997 Karlbohm 1997 1997 Patankar Dailianas 2000 Glia 1997 Ko 1997 Ko Chiotakakou-Faliakou 100 CTT, MN, EMG PPC Biofeedback for Constipation 131 symptoms Symptoms bloating and pain bloating Symptoms EMG activity during strain use Laxative Frequency of spontaneous BM Frequency and enema use Laxative improvement Symptom EMG activity with Valsalva Anismus index BM frequency Straining improvement Symptom EMG activity DF Improved Rectal sensation use Laxative Anismus index Anorectal angle < < BE 60cc psyllium slurryEliminate < > < > < > > < > < > > < < > straining BM frequency view 58% Symptom improvement rium enema; PPC, puborectalis contraction; paradoxical NR, not Clinical improvement 6mo BE, EMG 100% > 6 × 3 No MN, DF, EMG 89% vs 86% 8–11 No Diary EMG—73% Symptom improvement 3 1–8mo inter Telephone > MN, EMG balloon score Constipation BE—22% EMG, BE relax CTT, BE 7 MN, DF, CTT, EMG9 MN, DF, CTT, PPC 35.7 PPC9 MN, relax MN, DF, CTT, EMG, BE 49.4 IC EMG, BE, 41 4–5 EMG 2–4yr 2 Diary 5 85.7% 6 Diary frequency Stool 77.8% BM frequency 12 MN, DF, CTT, EMG, BE IC 62 EMG 6862 MN, DF, CTT, EMG MN, DF, CTT, EMG PPC15 PPC MN, EMG, 65.927 48 MN, DF, BE EMG60 MN, BE CTT, EMG, BE PPC20 MN, DF, PPC 41.2 PPC21 Psychotherapy, 46 11 MN, EMG, DF, BE 4 40.5 MN, BE IC PPC 16 No 14.9 34 37 6–10mo Diary and questionnaire EMG vs 25/85% Diary NR 1–1018 1–36mo 1–7 MN, DF, CTT, or unimproved Improved EMG NR PPC 2–3mo15 90.3% MN, 66.7% BE 2–6 Diary 67.7 EMG16 6–12mo22 MN, DF, BE, 51.8% of symptoms recovery Complete CTT, EMG Diary10 MN PPC PPC DF, CTT, EMG 50% 45 42.5 disappearance of Complete 9 Defecometer PPC EMG IC 50% 32 1–17 1 EMG, BE Diary 2/d MN 0 6.2 Daily Defecometer 88.9% 7 DF, diary 2–4 68.7% NR Spontaneous BM frequency 0 86.7% balloon Ability expel to NR 70% 18.2% Spontaneous BMs Daily spontaneous BM 46 47 48 48 52 45 54 51 53 56 55 44 50 26 28 43 49 1994 Fleshman 1992 Fleshman Kawimbe 1991 Wexner 1992 Wexner Leroi 1996 Leroi 1994 Koutsomanis 1987 Bleijenberg 1995 Keck Dahl 1991 Park 1996 Park Ho 1996 1987 Weber 1995 Bleijenberg MN, manometry; CTT, tranist time; colon Colo, colonoscopy; IC, constipation; idiopathic BE, balloon expulsion; DF, cinedefecography; BEN, ba iproudhis 1995 iproudhis 1995 Koutsomanis Papachrysostomou 22 MN, DF, CTT, EMG, BE PPC 42 EMG 1991 Lestar reported. Turnbull 1992 Turnbull 132 Constipation to comply with treatment protocols was the most in nature.27 Furthermore, diagnostic data from important predictor of success. physiologic testing beyond confirmation of Although feedback of information is essential spastic pelvic floor syndrome is often not for learning, the information itself, and the reported. Patient’s concomitant conditions dis- instrument providing the information, has no close a significant variance in inclusion criteria inherent power to create psychophysiologic (e.g., presence of rectoceles, rectal sensory changes in humans. Therefore, to establish a thresholds, previous surgery), which presumably double-blind, placebo-controlled research pro- contribute to the success of treatment.27 Park et tocol for biofeedback therapy, based on the prin- al28 described two varieties of anismus, anal ciples used for medication trials, becomes canal hypertonia, and nonrelaxation of the pub- inherently difficult. Studies based on under- orectalis muscle that appear to correlate with the standing the essentials of biofeedback training success of biofeedback; specifically, anal canal are often successful.10 In 1991, Dahl et al26 hypertonia may be responsible for failure of defined their teaching methods of sensory biofeedback therapy. McKee et al29 concluded awareness, shaping by teaching patients the that biofeedback for outlet obstruction consti- correct sphincter responses, home practice, pation is more likely to be successful in patients physiologic quieting methods, generalization, without evidence of severe pelvic floor damage. and weaning of equipment. There was a reported Biofeedback is a conservative treatment symptom improvement success rate of 78% for option for patients with idiopathic constipation, patients with anismus. Rao et al’s21 study is although some studies have had less favorable another example of defined teaching methods results. The most recent study, by Emmanuel and employing the essentials of biofeedback training Kamm22 in 2001, reported on 49 patients with and reporting 100% success; their defined idiopathic constipation pre- and postbiofeed- success is >50% symptomatic improvement. back using objective measurements as well as They concluded that biofeedback therapy effec- patient symptom diaries, and found that tively improves objective and subjective param- symptomatic improvement occurred in 59% of eters of anorectal function in patients with fecal patients. Twenty-two patients had slow transit incontinence. They noted that customizing the before treatment, of whom 14 felt symptomatic number of sessions and providing periodic rein- improvement, and 13 developed normal colonic forcement may improve success. transit. There was a significant increase in rectal mucosal blood flow in patients who subjectively improved. The authors concluded that successful Treatment of Constipation response to biofeedback for constipation is associated with specifically improved autonomic The many variants in these clinical trials may innervation to the large bowel and improved account for the wide range of success rates of transit time. In 1998, Chiotakokowi-Faliakou et 30% to 100% (Table 13.6). The number of treat- al30 studied 100 patients treated with biofeed- ment sessions varies significantly from one back and reported that 65% had slow transit and session of outpatient training to 2 weeks of daily 59% had paradoxical puborectalis contraction inpatient training, followed by additional subse- on straining. Long-term follow-up at 23 months quent home training. Rao et al’s6 review noted revealed that 57% of patients had felt their con- that the end point for successful treatment has stipation improved. Reiger et al31 evaluated the not been clearly defined and the duration of results of biofeedback to treat 19 patients with follow-up has also been quite variable. Enck and intractable constipation of no specific etiology Musial27 point out that comparing clinical and concluded that biofeedback had little thera- symptoms prior to and after treatment usually peutic effect. In these cases, Wexner32 reports assesses treatment efficacy; however, other patients remain symptomatic, requiring the studies have reported evaluation of sphincter inconvenience and expense of the use of cathar- performance during physiologic testing. tics. Engel and Kamm13 showed that excessive Outcome was sometimes assessed by diary straining has both acute and chronic effects on cards; however, reviews, telephone interviews, pudendal nerve latencies. Long symptom dura- and questionnaires were more often used. These tion with intense straining would thus induce evaluation techniques are unreliable when the nerve damage. It has also been reported that the recorded event, such as defecation, is infrequent chronic use of laxatives induces changes in the Biofeedback for Constipation 133 myenteric nerve plexa.32 Wexner suggested an 10. Shellenberger R, Green JA. From the Ghost in the Box alternate course of action would be to explain to to Successful Biofeedback Training. Greeley Co: Health Psychology Publication, 1986. patients that, although success of only 40% to 11. MacLeod JH. Management of anal incontinence by 60% can be anticipated, the success rate is deter- biofeedback. Gastroenterology 1987;93:291–294. mined by their willingness to complete the 12. Rao SSC. The technical aspects of biofeedback therapy course of therapy. Patients should be counseled for defecation disorders. Gastroenterologist 1998;6:96– 103. that biofeedback therapy is the only recourse 13. Engel AF, Kamm MA. The acute effect of straining on other than the continued use of laxatives and pelvic floor neurological function. Int J Colorectal Dis cathartics.36 Moreover, the lack of any known 1994;9:8–12. morbidity supports the logic of trying biofeed- 14. Binnie NR, Kawimbe BM, Papachrysotomou M, Clare back despite the relatively low success rate. N, Smith AN. The importance of the orientation of the electrode plates in recording the external anal sphincter EMG by non-invasive anal plug electrodes. Int J Col- orectal Dis 1991;6:8–11. 15. Hulme JA. Beyond Kegels. Phoenix: Phoenix Publish- Conclusion ing, 1997. 16. Lennard-Jones JE. Constipation. In: Feldman M, Fried- Despite the many variants in the clinical trials man L, Sleisenger MH, eds. Sleisinger and Fordtran’s for biofeedback, most experts agree that biofeed- Gastrointestinal and Liver Disease: Pathophysiology / back is an attractive outpatient, conservative Diagnosis / Management, 7th ed. Philadelphia: W.B. Saunders, 2002:81–209. treatment option that is cost-effective, relatively 17. Kegel A. The physiologic treatment of poor tone and noninvasive, easy to tolerate, morbidity free, and function of the genital muscles and of urinary stress does not interfere with any future treatment incontinence. West J Surg Obstet Gynecol 1949;57: options that may be recommended by the physi- 527–535. 18. Bump RC, Hurt WG, Fantl JA, Wyman JF.Assessment of cian. It is gratifying to note that this simple tech- Kegel pelvic muscle exercise performance after brief nique can ameliorate symptoms and improve the verbal instruction. Am J Obstet Gynecol 1991;165: quality of life in many patients with functional 322–329. bowel and bladder symptoms attributed to 19. Basmajian JV. Biofeedback: Principles and Practice for pelvic muscle dysfunction. It should be available Clinicians. Baltimore: Williams & Wilkins, 1989. 20. Charlesworth EA, Nathan RG. Stress Management: A in every pelvic floor physiology unit. Comprehensive Guide to Wellness. New York: Ballan- tine, 1985. 21. Rao SSC, Welcher KD, Happel J. Can biofeedback therapy improve anorectal function in fecal inconti- References nence? Am J Gastroenterol 1996;91:2360–2365. 22. Emmanuel AV, Kamm MA. Response to a behavioral 1. Sonnenberg A, Koch TR. Physician visits in the United treatment, biofeedback in constipated patients is asso- States for constipation. Dig Dis Sci 1989;34:606. ciated with improved gut transit and autonomic inner- 2. Sonnenberg A, Koch TR. Epidemiology of constipation vation. Gut 2001;49:214–219. in the United States. Dis Colon Rectum 1989;32:1–8. 23. Hyman S, Jones KR, Ringel Y,Scarlett Y,Whitehead WE. 3. Thompson WG, Longstreth GF, Drossman DA, Heaton Biofeedback treatment of fecal incontinence. Dis Colon KW,Irvien EJ, Muller-Lissner SA. Functional bowel dis- Rectum 2001;44:728–736. orders and functional abdominal pain. Gut 1999;45: 24. Norton C, Kamm MA. Outcome of biofeedback 1143–1154. for faecal incontinence. Br J Surg 1999;86:1159– 4. Jorge JMN, Wexner SD. Physiologic evaluation. In: 1163. Wexner SD, Vernava AM III, eds. Clinical Decision 25. Gilliland R, Heymen S, Altomare DF, Park UC, Vickers Making in Colorectal Surgery. New York: Igaku-Shoin, D, Wexner SD. Outcome and predictors of success of 1995:11–22. biofeedback for constipation. Br J Surg 1997;84:1123– 5. Wexner SD, Jorge JMN. Colorectal physiological tests: 1126. use or abuse of technology? Eur J Surg 1994;160:167– 26. Dahl J, Lindquist BL, Leissner P,Philipson L, Jarnerot G. 174. Behavioral medicine treatment in chronic constipation 6. Rao SSC, Welcher KD P, Leistikow JS. Obstructive defe- with paradoxical anal sphincter contraction. Dis Colon cation: a failure of rectoanal coordination. Am J Gas- Rectum 1991;34:769–776. troenterol 1998;93:1042–1050. 27. Enck P, Musial F. Biofeedback in pelvic floor disorders. 7. Hallan RI, Williams NS, Melling J, Walron DJ, Womack In: Pemberton JH, Swash M, Henry MM, eds. The Pelvic NR, Morrison J. Treatment of anismus in intractable Floor: Its Function and Disorders. London: W.B. constipation with botulinum toxin. Lancet 1988;2: Saunders, 2002:393–404. 714–717. 28. Park UC, Choi SK, Piccirillo MF,Verzaro R, Wexner SD. 8. Enck P. Biofeedback training in disordered defecation: Patterns of anismus and the relation to biofeedback a critical review. Dig Dis Sci 1993;38:1953–1959. therapy. Dis Colon Rectum 1996;39:768–773. 9. Schwartz MS, et al. Biofeedback: A Practitioner’s Guide, 29. McKee RF, McEnroe L, Anderson JH, Finaly IG. 2nd ed. New York: Guilford Press, 1995. Identification of patients likely to benefit from 134 Constipation

biofeedback for outlet obstruction constipation. Br J 43. Ho YH, Tan M, Goh HS. Clinical and physiologic effects Surg 1999;86:355–359. of biofeedback in outlet obstruction defecation. Dis 30. Chiotakakou-Faliakou E, Kamm MA, Roy AJ, Storrie JB, Colon Rectum 1996;39:520–524. Turner IC. Biofeedback provides long term benefit for 44. Leroi AM, Duval V, Roussignol C, Berkelmans I, patients with intractable slow and normal transit con- Reninque P,Denis P.Biofeedback for anismus in 15 sex- stipation. Gut 1998;6:517–521. ually abused women. Int J Colorect Dis 1996;11:187– 31. Rieger NA, Wattchow DA, Sarre RG, et al. Prospective 190. study of biofeedback for treatment of constipation. Dis 45. Siproudhis L, Dautreme S, Ropert A, et al. Anismus and Colon Rectum 1997;40:1143–1148. biofeedback: who benefits? Eur J Gastroenterol Hepatol 32. Wexner SD. Biofeedback for constipation. Dis Colon 1995;7:547–552. Rectum 1998;41:670–671. 46. Koutsomanis D, Lennard-Jones JE, Roy AJ, Kamm MA. 33. Smith B. Effect of irritant purgatives on the myenteric Controlled randomized trial of visual biofeedback plexus in man and the mouse. Gut 1968;9:139–143. versus muscle training without a visual display for 34. Dailianas A, Skandalis N, Rimikis MN, Koutsomanis D, intractable constipation. Gut 1995;37:95–99. Kardasi M, Archimandritis A. Pelvic floor study in 47. Koutsomanis D, Lennard-Jones JE, Kamm MA. Prospec- patients with obstructive defecation. J Clin Gastroen- tive study of biofeedback treatment for patients with terol 2000;30:176–180. slow and normal transit constipation. Eur J Gastroen- 35. Lau C, Heymen S, Alabaz O, Iroatulam AJN, Wexner SD. terol Hepatol 1994;6:131–137. Prognostic significance of rectocele, intussusception, 48. Bleijenberg G, Kuijpers HC. Biofeedback treatment of and abnormal perineal descent in biofeedback treat- constipation: comparison of two methods. Am J Gas- ment for constipated patients with paradoxical pub- troenterol 1995;89:1021–1026. orectalis contraction. Dis Colon Rectum 2000;43:478– 49. Papachrysostomou M,Smith AN.Effects of biofeedback 482. on obstructed defecation—reconditioning of the defe- 36. Mollen RMHG, Salvioli B, Camilleri M, et al. The effects cation reflex. Gut 1994;35:252–256. of biofeedback on rectal sensation and distal colonic 50. Keck JO, Staniunas RJ, Coller YES, et al. Biofeedback motility in patients with disorders of rectal evacuation: training is useful in fecal incontinence but disappoint- evidence of an inhibitory rectocolonic reflex in ing in constipation. Dis Colon Rectum 1995;37:1271– humans. Am J Gastroenterol 1999;94:751–756. 1276. 37. Gila A, Gylin M, Gullberg K, Lindberg G. Biofeedback 51. Turnbull GK, Ritivo PG. Anal sphincter biofeedback retraining in patients with functional constipation and relaxation treatment for women with intractable con- paradoxical puborectalis contraction. Dis Colon stipation symptoms. Dis Colon Rectum 1992;35:530– Rectum 1997;40:889–895. 536. 38. Ko CY, Tong J, Lehman RE, Shelton AA, Schrock TR, 52. Fleshman JW, Dreznik Z, Meyer K, Fry RD, Carney R, Welton ML. Biofeedback is effective therapy for fecal Kodner IJ. Outpatient protocol for biofeedback therapy incontinence and constipation. Arch Surg 1997;132: of pelvic floor outlet obstruction. Dis Colon Rectum 829–834. 1992;35:1–7. 39. Patankar SK, Ferera A, Larach SW, et al. Electromyo- 53. Wexner SD, Cheape JD, Jorge JMN, Heyman SR, Jagel- graphic assessment of biofeedback training for fecal man DG. Prospective assessment of biofeedback for the incontinence and chronic constipation. Dis Colon treatment of paradoxical puborectalis contraction. Dis Rectum 1997;40:907–911. Colon Rectum 1992;35:145–150. 40. Karlbohm U, Hallden M, Eeg-Olofssson, Pahlman L, 54. Kawimbe BM, Papachrysostomou M, Clare N, Smith Graf W. Results of biofeedback in constipated patients. AN. Outlet obstruction constipation (anismus) A prospective study. Dis Colon Rectum 1997;40:1149– managed by biofeedback. Gut 1991;32:1175–1179. 1155. 55. Lestar B, Penninckx F, Kerremans R. Biofeedback defe- 41. Rao SSC, Welcher KD, Pelsan RE. Effects of biofeedback cation training for anismus. Int J Colorect Dis 1991; therapy on anorectal function in obstructive defeca- 6:202–207. tion. Dig Dis Sci 1997;42:2197–2305. 56. Weber J, Ducrotte P,Touchais JY, Roussignol C, Denis P. 42. Patankar SK, Ferrera A, Levy JR, Larach SW,Williamson Biofeedback training for constipation in adults and PR, Perozo SE. Biofeedback in colorectal practice. A children. Dis Colon Rectum 1987;30:844–846. multi center, statewide, three-year experience. Dis Colon Rectum 1997;40:827–831.