2004 biofeedback for pelvic floor disfunction in constp.pdf

Clinical review

Biofeedback for pelvic floor dysfunction in constipation

G Bassotti, F Chistolini, F Sietchiping-Nzepa, G de Roberto, A Morelli, G Chiarioni

Pelvic floor dyssynergia is one of the commonest subtypes of constipation, and the conventional

treatment (dietary fibre and laxatives) is often unsatisfactory. Recently biofeedback training has been

introduced as an alternative treatment. The authors review the evidence for this approach and

conclude that, although controlled studies are few and open to criticism, about two thirds of patients

with pelvic floor dyssynergia should benefit from biofeedback training

Chronic constipation is a common self reported

gastrointestinal problem that affects between 2% and

34% of adults in various populations studied. Among

the subtypes of constipation, obstructed defecation

seems particularly common, occurring in about 7% of

the adult population. 1 In most people with this

condition an inappropriate (paradoxical) contraction

or a failed relaxation of the puborectal muscle and of

the external anal sphincter often occurs during

attempts to defecate (fig 1). This paradoxical contrac-

tion of the pelvic floor muscles during straining at

defecation is considered a form of maladaptive

learning and is generally defined (without specifying

the underlying pathophysiological mechanism) as

outlet dysfunction constipation or, more precisely,

pelvic floor dyssynergia. 2

Cardinal symptoms of pelvic floor dyssynergia are

straining at stools and feelings of incomplete

evacuation, and the diagnostic criteria, recently

updated in the Rome II report, include those for func-

tional constipation (see box) 3 plus at least two out of

three investigations (radiology, manometry, and elec-

tromyography) showing inappropriate contraction or

failure to relax the pelvic floor muscles during attempts

to defecate. 2

Summary points

Gastroenterology

and Hepatology

Section,

Department of

Clinical and

Experimental

Medicine,

University of

Perugia, Via Enrico

Dal Pozzo, 06100

Perugia, Italy

G Bassotti

deputy chief

F Chistolini

gastroenterology fellow

F Sietchiping-Nzepa

gastroenterology fellow

G de Roberto

gastroenterology fellow

A Morelli

professor of

gastroenterology and

chief

Gastrointestinal

Rehabilitation

Division, Valeggio

sul Mincio Hospital,

Azienda

Ospedaliera and

University of

Verona, Valeggio

sul Mincio (VR),

Italy

G Chiarioni

deputy chief

Correspondence to:

G Bassotti, Strada

del Cimitero, 2/a,

06131 San Marco

(Perugia), Italy

gabassot@tin.it

Obstructed defecation is a common subtype of

constipation that may not be responsive to

treatment with laxatives and dietary fibre

Failure of the pelvic floor and anal muscles to

relax during straining (pelvic floor dyssynergia)

seems to be the commonest cause of obstructed

defecation

Biofeedback to teach patients to inhibit this

paradoxical behaviour has been proposed as an

effective treatment

Biofeedback is reported to benefit more than half

of patients with evidence of pelvic floor

dyssynergia, but mechanisms of action are still

unclear and controlled studies are lacking

The rationale of using biofeedback in

pelvic floor dyssynergia

The common treatment for chronic constipation is

with high dietary fibre and laxatives. However, some

patients (and especially those with pelvic floor dyssyn-

ergia) are unresponsive to these measures, which has

encouraged the use of alternative treatments such as

biofeedback training. 4 Biofeedback is thought to be

appropriate when specific pathophysiological mecha-

nisms are known, and the control of relevant responses

can be learnt with the aid of systematic information

about a function that is not usually monitored

consciously. 4 We have critically reviewed the evidence

on use of biofeedback to treat pelvic floor dyssynergia.

Normal

BMJ 2004;328:393–6

Pelvic floor

dyssynergia

Fig 1 Anorectal manometric tracings of a normal subject (upper

tracing) and a patient with pelvic floor dyssynergia (lower tracing)

during straining at defecation (arrows). Note that the normal subject

relaxes the anal sphincter, whereas the patient displays a paradoxical

contraction of the sphincter

Methods

We made a comprehensive online search of Medline

and the Science Citation Index using the keywords

Details of extra references w1-w8 appear on bmj.com

BMJ VOLUME 328 14 FEBRUARY 2004 bmj.com

393

Clinical review

“biofeedback,” “constipation,” and “pelvic floor dyssyn-

ergia” in various combinations with the Boolean

operators and , or , and not . We included only articles

that related to human studies, and we performed

manual cross referencing. We selected articles pub-

lished in English between January 1965 and Septem-

ber 2003, but a search in non-English languages and

among journals older than 1965 was also performed in

our library. We excluded letters, and we reviewed

abstracts only when the full papers were unavailable.

Two or more of the following for at least 12 weeks

(not necessarily consecutive) in the previous 12 months:

Straining in

25% of bowel movements

Lumpy or hard stools in

≥

25% of bowel movements

Sensation of incomplete evacuation in

≥

25% of bowel

movements

Sensation of anorectal obstruction or blockage in

≥

25% of bowel movements

Manual manoeuvres to facilitate

≥

25% of bowel

movements

Fewer than three defecations a week

•

Biofeedback techniques for treating

pelvic floor dyssynergia

Paradoxically increased anal pressure or electromyo-

graphic activity during straining is readily detected in

patients with pelvic floor dyssynergia. 4 Some authors

have measured the pressure gradient between the

rectum and the anus on straining, but its clinical

relevance is unclear. 5 Radiological examination of rec-

tal evacuation (defecography) has shown that pelvic

floor dyssynergia is associated with the contour of the

puborectal muscle increasing or the anorectal angle

decreasing (fig 2). In addition, the suspicion of

impaired defecation may be confirmed by the patient’s

inability to expel a rectal balloon. The diagnostic

relevance of other techniques (ultrasonography, evacu-

ation scintigraphy, pelvic floor magnetic resonance

imaging, etc) is under evaluation.

The three main biofeedback techniques used to

treat pelvic floor dyssynergia are sensory training, elec-

tromyographic feedback, and manometric feedback. 6

However, it should be remembered that measurements

of pelvic floor dyssynergia may vary in different situa-

tions, likely to be minimal during home ambulatory

monitoring and maximal under laboratory condi-

tions. w1 Some authors provide additional sensory

retraining to lower defecation threshold by means of

progressively reducing the distension volume of a

rectal balloon. 5 The use of rectal sensory retraining is

well standardised in faecal incontinence, 7 but its clinical

relevance in constipation is not yet confirmed.

Loose stools not present, and insufficient criteria for

irritable bowel syndrome

Children

•

Pebble-like, hard stools for most bowel movements

for

≥

2 weeks

•

Firm stools less than two times a week for

≥

2 weeks

No evidence of structural, endocrine, or metabolic

disease

Sensory training was the first biofeedback technique

to be used in clinical practice. It entails simulated

defecation by means of a water filled balloon

introduced in the rectum; this is then slowly withdrawn,

while patients are asked to concentrate on the

sensations evoked by the balloon and to try to ease its

passage. 8 Variations of this technique involve defeca-

tion of a balloon or simulated stools to improve

defecatory dynamics. 9

Electromyography consists of recording a patient’s

averaged electromyographic activity from the pelvic

floor muscles for training. 10 Measurements may be

obtained from intraluminal probes or from surface

electrodes taped to the perianal skin. By watching the

recording, the patient first learns to relax the pelvic

floor muscles during attempts to defecate, and then

gradually increases straining efforts to increase

intra-abdominal pressure while keeping the pelvic

floor muscles relaxed. 6

Manometry —Anal canal pressure can also be

measured (by means of balloons, perfused catheters, or

solid-state probes) to detect the contraction and

relaxation of the pelvic floor muscles. 6 The training

procedures are almost identical to those described

above for electromyographic training.

Few studies have compared the different biofeed-

back protocols. No differences were reported between

electromyographic biofeedback and simulated defeca-

tion in one study, 11 whereas a recent meta-analysis

showed that the mean success rate with manometric

biofeedback was superior to that with electromyo-

graphic biofeedback (78% v 70%). 12 No differences were

found between different electromyographic techniques.

Fig 2 Representative defecographic sequence of a patient with pelvic floor dyssynergia,

showing insufficient opening of the anal canal and of the anorectal angle, with most of the

contrast medium retained after straining. The sequence shows resting (upper left),

contracting (upper right), straining (lower left), and after straining (lower right)

Effectiveness of biofeedback in treating

pelvic floor dyssynergia

Literature reviews conclude that more than 70% of

adult patients complaining of pelvic floor dyssynergia

are likely to benefit from biofeedback training, 6 and so

this is the treatment of choice for the problem. Unfor-

tunately, most data on the outcome of biofeedback in

394

BMJ VOLUME 328 14 FEBRUARY 2004 bmj.com

Rome II criteria for constipation

Adults

•

Clinical review

Patient’s personal account

I am a 26 year old single woman. I never suffered from

major diseases, but I used to be constipated since

childhood. I took it for granted, since all my family’s

women are also constipated. When I felt the morning

call to stools I went to the toilet, but I had to strain

hard to expel some little pellets. I often had to sit on

the toilet for about half an hour to empty my bowel. If

I did not succeed, I felt bloated the whole day, and the

call to stools went on and on.

I tried many laxatives without satisfaction; enemas

worked a bit better, but sometimes I had difficulties even

emptying liquid stools. Fibre did not help and increased

bloating. After organic disease was excluded, I was sent

to Dr Chiarioni, who diagnosed pelvic floor dyssynergia

by means of an anorectal manometry. He explained me

that my problem was related to the paradoxical closure

of the anal canal on straining. Then I was instructed to

inhibit this behaviour by electromyographic

biofeedback. The treatment worked well, and now I

evacuate once a day with ease. I was surprised and

pleased by this chance of self healing my problem.

Long term efficacy of biofeedback and predictors

of outcome

The few studies with long term follow up data are

uncontrolled and often include patients with various

subtypes of constipation. Most studies on biofeedback

training report good short term efficacy, mirrored by

an improved psychological state and quality of life, 21

whereas the few follow up studies indicate a fading

effect over time. 22 w2 However, a certain percentage of

patients (up to 50% and more) continued to report sat-

isfaction even at 12-44 months after treatment. 23 w3

The various biofeedback protocols used make it dif-

ficult to assess those factors that affect outcome, and this

is exacerbated by the lack of proper definition of such

factors. Manometric demonstration of paradoxical

sphincter contraction during straining does not seem to

predict response to biofeedback, and the success of this

treatment seems to be related to the number of training

sessions. 24 Anatomical factors and the presence of

significant psychological symptoms (such as affective

disorders, distorted attitudes about food, and history of

sexual abuse) may also play a role. 23 w4 w5 The size of

improvement in anorectal pressure gradient, or in anal

electromyographic activity on straining, does not seem

to be relevant to treatment outcome. 12 Similarly, the

association of a colon motility disorder (so called slow

transit constipation) with pelvic floor dyssynergia does

not seem to affect the clinical outcome, w3 although

recent evidence indicates that biofeedback treatment

benefits only constipated patients with functional

evidence of pelvic floor dyssynergia (Chiarioni G,

Salandini M, Whitehead WE. Digestive Disease Week,

San Francisco, 19-22 May 2002. Abstract book: A-123).

pelvic floor dyssynergia come from single group,

uncontrolled studies, often with different selection cri-

teria for patients. 16 Few controlled studies have been

done, mainly in children.

Biofeedback in children— A study of children with faecal

incontinence, 18 of whom had pelvic floor dyssynergia,

compared manometric biofeedback with mineral oil. 13

Although there was a trend toward greater improve-

ment with biofeedback for the children with pelvic floor

dyssynergia, no significant differences were found. In

another study, on children with pelvic floor dyssynergia,

manometric and electromyographic biofeedback pro-

duced significantly greater improvement than conven-

tional treatment (laxatives). 14 However, two other

paediatric studies comparing biofeedback with laxatives

failed to find any benefit with biofeedback treatment, 15 16

although one of the studies also included children with-

out pelvic floor dyssynergia. 15 A recent investigation in

constipated children that compared biofeedback train-

ing with conventional treatment showed that biofeed-

back was effective in the short term, 17 but no clear

evidence for long term benefits was reported.

Biofeedback in adults— The few controlled studies

done include small numbers of patients, too few to

draw firm conclusions. One study of patients with

pelvic floor dyssynergia reported that 90% of those

treated by intra-anal electromyographic biofeedback

improved compared with 60% of those given balloon

defecation training. 18 A second study, of constipated

patients (two thirds with pelvic floor dyssynergia), com-

pared electromyographic biofeedback training to

defecate a balloon with balloon defecation training

without visual feedback and showed no difference in

efficacy between treatments (69% v 64%). 19 Another

study compared four biofeedback approaches (electro-

myographic training alone, electromyography plus

rectal balloon defecation, electromyography plus daily

use of a home biofeedback trainer, and the above com-

bined); it found no differences between groups, but the

first three groups showed a significant decrease in the

use of laxatives and all but the third group showed a

significant increase in the frequency of spontaneous

bowel movements. 20

Additional educational resources

Azpiroz F, Enck P, Whitehead WE. Anorectal

functional testing: review of collective experience.

Am J Gastroenterol 2002;97:232-40

Brazzelli M, Griffiths P. Behavioural and cognitive

interventions with or without other treatments for

defaecation disorders in children. Cochrane Database

Syst Rev 2001;(4):CD002240

Diamant NE, Kamm MA, Whitehead WE. AGA

technical review on anorectal testing techniques.

Gastroenterology 1999;116:735-60

Drossman DA, Corazziari E, Talley NJ, Thompson WG,

Whitehead WE, eds. Rome II: the functional gastrointestinal

disorders . McLean, VA: Degnon Associates, 2000

Useful websites for patients and physicians

National Digestive Diseases Information Clearinghouse

(NDDIC) (http://digestive.niddk.nih.gov/ddiseases/

pubs/constipation/index.htm)—Simple, easy to read

information on the main aspects of constipation,

including treatments

BIOME, OMNI (http://omni.ac.uk./browse/mesh/

detail/C0009806L0009806.html)—Educational site

with multiple links related to constipation

Medlineplus Health Information (www.nlm.nih.gov/

medlineplus/constipation.html)—Comprehensive, in

depth information on constipation from the National

Institute of Health

Association for Applied Psychophysiology and

Biofeedback (www.aapb.org/)—Dedicated to research,

clinical applications, and public information on

biofeedback and related sciences

BMJ VOLUME 328 14 FEBRUARY 2004 bmj.com

395

Clinical review

Conclusions

Notwithstanding some pessimistic views about the

effects of biofeedback interventions for gastrointestinal

conditions, w6 biofeedback training seems to be a good

treatment for lower gastrointestinal disturbances, espe-

cially for pelvic floor dyssynergia. The effects of such

training may not be limited to the anorectum and

might also be useful in other conditions in which pelvic

floor dyssynergia plays a role. w7

However, good quality research in this subject is

lacking. Validated scoring systems and quantitative

tests are still needed, as well as more uniform and strict

criteria for pelvic floor dyssynergia. 1 For good quality

studies, we also need improved experimental designs,

larger numbers of participants, clearly defined

outcome measures, knowledge of the best treatment

protocol, and long term follow up. 12 Finally, it remains

to be established whether other promising treatments

for pelvic floor dyssynergia, whether used alone 25 or in

combination with biofeedback, w8 could provide better

clinical outcomes.

13 Wald A, Chandra R, Gabel S, Chiponis D. Evaluation of biofeedback in

childhood encopresis. J Pediatr Gastroenterol Nutr 1987;6:554-8.

14 Loenig-Baucke V. Modulation of abnormal defecation dynamics by bio-

feedback treatment in chronically constipated children with encopresis. J

Pediatr 1990;116:214-22.

15 Van der Plas RN, Benninga MA, Buller HA, Bossuyt PM, Akkermans LM,

Redekop WK, et al. Biofeedback training of childhood constipation: a

randomized controlled study. Lancet 1996;348:776-80.

16 Nolan TM, Catto-Smith T, Coffey C, Wells J. Randomised controlled trial

of biofeedback training in persistent encopresis with anismus. Arch Dis

Child 1998;79:131-5.

17 Sunic-Omejc M, Mihanovic M, Bilic A, Jurcic D, Restek-Petrovic B, Maric

N, et al. Efficiency of biofeedback therapy for chronic constipation in

children. Coll Antropol 2002;26(suppl):93-101.

18 Bleijenberg G, Kuijpers HC. Biofeedback treatment of constipation: a

comparison of two methods. Am J Gastroenterol 1994;89:1021-6.

19 Koutsomanis D, Lennard-Jones JE, Roy AJ, Kamm MA. Controlled rand-

omized trial of visual biofeedback versus muscle training without a visual

display for intractable constipation. Gut 1995;37:95-9.

20 Heymen S, Wexner SD, Vickers D, Nogueras JJ, Weiss EG, Pikarsky AJ.

Prospective, randomized trial comparing four biofeedback techniques for

patients with constipation. Dis Colon Rectum 1999;42:1388-93.

21 Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological state and quality

of life in patients during behavioral treatment (biofeedback) for intracta-

ble constipation. Am J Gastroenterol 2002;97:3154-9.

22 Battaglia E, Serra AM, Buonafede G, Dughera L, Chistolini F, Morelli A,

et al. Long-term study on the effects of visual biofeedback and muscle

training as a therapeutic modality in pelvic floor dyssynergia and

slow-transit constipation. Dis Colon Rectum 2004;47:90-5.

23 Wang J, Luo MH, Hui Q, Dong ZL. Prospective study of biofeedback

retraining in patients with chronic idiopathic functional constipation.

World J Gastroenterol 2003;9:2109-13.

24 Gilliland R, Heymen S, Altomare DF, Park UC, Vickers D, Wexner SD.

Outcome and predictors of success of biofeedback for constipation. Br J

Surg 1997;84:1123-6.

25 Chiarioni G, Chistolini F, Menegotti M, Salandini L, Vantini I, Morelli A,

et al. A one-year follow-up study on the effects of electrogalvanic stimula-

tion in chronic idiopathic constipation with pelvic floor dyssynergia. Dis

Colon Rectum (in press).

Contributors: GB and GC conceived of and planned the review,

and wrote the final draft. FC, FSN, GdR, and AM did the literature

search, wrote the first draft, and helped in evaluating the review.

Funding sources: None.

Competing interests: None declared.

1 D’Hoore A, Penninckx F. Obstructed defecation. Colorectal Dis

2003;5:280-7.

2 Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SSC.

Functional disorders of the anus and rectum. In: Drossman DA,

Corazziari E, Talley NJ, Thompson WG, Whitehead WE, eds. Rome II: the

functional gastrointestinal disorders . McLean, VA: Degnon Associates,

2000:483-529.

3 Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ,

Muller-Lissner SA. Functional bowel disorders and functional abdominal

pain. Gut 1999;45(suppl II):II43-7.

4 Bassotti G, Whitehead WE. Biofeedback, relaxation training, and

cognitive behaviour modification as treatments for lower functional

gastrointestinal disorders. Q J Med 1997;90:545-50.

5 Rao SC, Welcher KD, Pelsang RE. Effects of biofeedback therapy on

anorectal function in obstructive defecation. Dig Dis Sci 1997;42:2197-205.

6 Whitehead WE, Heymen S, Schuster MM. Motility as a therapeutic

modality: biofeedback treatment of gastrointestinal disorders. In:

Schuster MM, Crowell MD, Koch KL, eds. Schuster atlas of gastrointestinal

motility. 2nd ed. Hamilton, Ontario: BC Decker, 2002:381-97.

7 Chiarioni G, Bassotti G, Stanganini S, Vantini I, Whitehead WE. Sensory

retraining is key to biofeedback therapy for formed stool fecal

incontinence. Am J Gastroenterol 2002, 97:109-17.

8 Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor with

biofeedback. Dis Colon Rectum 1987;30:108-11.

9 Kawimbe BM, Papachysostomou M, Binnie NR, Clare N, Smith AN.

Outlet obstruction constipation (anismus) managed by biofeedback.

Gut 1991;35:1175-9.

10 Cox DJ, Sutphen J, Borowitz S, Dickens MN, Singles J, Whitehead WE.

Simple electromyographic biofeedback treatment for chronic pediatric

constipation/encopresis: preliminary report. Biofeedback Self Regul

1994;19:41-50.

11 Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining in

patients with functional constipation and paradoxical puborectalis

contraction: comparison of anal manometry and sphincter electromyog-

raphy for feedback. Dis Colon Rectum 1997;40:889-95.

12 Heymen S, Jones KR, Scarlett Y, Whitehead WE. Biofeedback treatment

of constipation: a critical review. Dis Colon Rectum 2003;46:1208-17.

Corrections and clarifications

Use of automated external defibrillator by first responders

in out of hospital cardiac arrest: prospective controlled trial

We inadvertently reversed two numbers in figure 1

of this paper by Anouk P van Alem and colleagues

( BMJ 2003;327:1312-5). In the experimental group,

82 of the 157 participants in the “initial rhythm

shockable” category were admitted to hospital. This

represents 52% (not 25% as we stated).

Cognitive behaviour therapy affects brain activity

differently from antidepressants

The news team has been a bit slow in adjusting to

the new year. In this news article by Sue Mayor

(10 January, p 69), the reported study was published

in 2004 (not 2003, as we said). The correct reference

is Archives of General Psychiatry 2004;61:34-41.

Career Focus

In the article “The way forward for non-standard

grade (trust) doctors” by Rhona MacDonald

(3 January, p s9), we were wrong to say that

Professor Sam Lingam is the “former chairman of

the British International Doctors Association”; he is

in fact the current chairman of the association’s

Hospital Doctors’ Forum. The association has

asked us to point out to readers that the views

expressed by Professor Lingam were not the views

of the association.

Interactive case report

Treating nausea and vomiting during pregnancy

This case was described on 31 January and 7 February ( BMJ

2004;276,337). Debate on the management of this case and

the n of 1 trial continues on bmj.com (http://bmj.com/cgi/

content/full/328/7434/276). On 7 March we will publish the

outcome of the case together with commentaries on the

issues raised by the management and online discussion from

a general practitioner, an obstetrician, a statistician, and an

educationalist.

396

BMJ VOLUME 328 14 FEBRUARY 2004 bmj.com

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: