Rectal Biofeedback

BIOFEEDBACK FOR CONSTIPATION — Biofeedback is a behavioral approach that may help some people with severe chronic constipation who involuntarily squeeze (rather than relax) their muscles while having a bowel movement.

Indications are :
• The patient has chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy.
• The patient has slow colonic transit of the inertia pattern.
• The patient does not have intestinal pseudoobstruction, as demonstrated by radiologic or manometric studies.
• The patient does not have abdominal pain as a prominent symptom.

Biofeedback Treats One Type Of Chronic Constipation
Chronic constipation affects 15 to 20 percent of the U.S. population. Nearly one-third of affected people have dyssynergic defecation, in which muscles used for bowel movements do not work well, but there’s some good news. University of Iowa research shows biofeedback treatment can successfully retrain muscles.

The biofeedback approach was better than standard treatment of laxatives, diet and exercise or another treatment (sham) that included muscle relaxation and coping strategies.

Many people with dyssynergic defecation have life-long constipation and experience significant difficulty with passing stools but are unaware that they have this particular type of chronic constipation, said Satish Rao, M.D., professor of internal medicine at the UI Roy J. and Lucille A. Carver College of Medicine.

“People with dyssynergic defecation cannot sense stool in their bowel or have difficulty using bodily mechanisms to expel the stool. However, they often don’t seek help beyond using over-the-counter laxatives, and some doctors aren’t aware of the condition either,” Rao said.

The biofeedback technique involves making people more aware of unconscious or involuntary bodily functions involved in defecation. The technique includes placing a pencil-thin probe into the rectum to provide feedback information about how the body muscles are performing. This data, as well as visual and verbal feedback techniques, help individuals relearn the normal process of having a bowel movement.

The study included 79 adults, with an average age of 43, who had dyssynergic defecation. The 69 female and eight male participants were randomly assigned to one of three study groups: standard, biofeedback or “sham” biofeedback.
In the biofeedback group, 79 percent of the individuals had corrected bowel function at the end of the study. In contrast, only 4 percent of the sham group and slightly more than 8 percent of the standard group showed corrected muscle function.

“We did the study to find out: Is it medical attention and coping strategies or alterations in muscle-function that really make a difference with biofeedback?” Rao said. “The study results show that bowel movement improvement is possible in nearly 80 percent of patients through biofeedback.”

Standard treatment included use of laxatives, education about bowel habits, exercise for overall physical and abdominal muscle strengthening, and dietary advice such as increasing fiber and fluid intake.

The biofeedback group received standard treatment plus six training sessions over three months in which the participants practiced pushing with a probe in the rectum and pushing out artificial stools.

“We showed the biofeedback group how to improve their pushing effort and relax the pelvic floor and anal sphincter muscles so that they can poop normally and easily,” Rao said. “The probe gives us information about how the muscles are working.”

The sham biofeedback group received standard care plus six training sessions over three months. They practiced pushing using the probe but, unlike the true biofeedback group, did not use the artificial stool and were not instructed in how to push or relax muscles. They were provided attention in the form of coping strategies and muscle relaxation tapes.

In addition to using objective anal/rectal muscle function measures, the team used a second objective measure and found that people in the biofeedback group were able to expel an artificial stool in less time than it took participants in the other groups.

“There’s no question from the objective data that the biofeedback treatment is far superior than standard treatment,” Rao said.

The study also included two subjective measures of differences among the three treatments. Entries from participants’ diaries indicated that people in the biofeedback group, not standard or sham groups, had more spontaneous bowel movements. All groups reported more satisfaction overall with their bowel habits. However, 85 percent of the biofeedback group reported improvement, compared to 45 percent of the “sham” group.

The researchers are now developing a home-based biofeedback program to assist more people. They also are studying the mechanism by which the biofeedback succeeds.

“Biofeedback works, but we don’t know exactly why it does,” Rao said. “We’ll study how the gut and brain ‘talk to each other’. Somewhere in between is where the problem lies, so improving communication, if you will, between the gut and brain will improve bowel function.”

Dr. Satish Rao and colleagues at the University of Iowa Hospitals and Clinics in Iowa City, found that biofeedback using sensors monitoring the bowel and anus can indeed help train adults with this type of chronic constipation to have normal bowel movements. While an earlier study by Rao’s team showed a benefit at three months, their current study showed benefits lasting out to one year.

Rao, a gastroenterologist, told Reuters Health in a telephone interview that this particular type of chronic constipation has only been recognized over the past 15 years and affects more than 10 million Americans. For unexplained reasons, dyssynergic defecation occurs in twice as many women as men. The condition can interfere with a person’s social life and ability to hold down a job.

“Dyssynergic defecation is grossly unrecognized and consequently not well-treated,” Rao said. “Many doctors don’t know about it or how to manage this problem.”

The Iowa team compared the one-year outcome of biofeedback training with standard care in 26 chronically constipated patients with dyssynergic defecation. All of them received standard instruction regarding bowel habits, exercise and breathing techniques, use of laxatives, and the importance of eating a high-fiber diet.
They were also encouraged to attempt a bowel movement 30 minutes after eating for five minutes twice a day irrespective of the urge to defecate

Thirteen of the patients underwent six biofeedback sessions during the first three months and then reinforcing sessions at three-month intervals. During biofeedback training, a probe with sensors is inserted rectally. The sensor detects the muscle signals from the anus and rectum and displays them visually on a TV monitor. While sitting on the toilet, the subjects are able to see how these muscles are contracting or relaxing and with the visual feedback learn how to coordinate them to improve their push movements.

The biofeedback patients had a significant increase in normal bowel movements and normal bowel patterns, whereas no improvement occurred in the 13 control patients who did not receive biofeedback training, the researchers report in the American Journal of Gastroenterology.

In addition, roughly 30 percent of the biofeedback patients stopped taking laxatives, whereas none of the subjects in the control group stopped using laxatives at the one-year point.

In a telephone interview with Reuters Health, Dr. Lin Chang of the David Geffen School of Medicine atUniversity of California, Los Angeles, who was not involved in the study, said these one-year results, coupled with another recent study, suggest that biofeedback is “the treatment of choice” for patients with dyssynergic defecation. The Iowa study, Chang said, “shows that even if you follow a patient who underwent biofeedback out for a year, they all do well as opposed to those who don’t get biofeedback.”

Chang said biofeedback is not widely used for constipation and only is offered at a few specialized centers because insurance generally won’t cover it. According to Rao, fees for biofeedback vary from institution to institution and state to state, ranging from $125 to $600 per session.

Rao is hopeful that controlled studies, such as the Iowa study, will help persuade insurance companies to cover the therapy. “It’s so difficult when you see patients who could benefit from biofeedback, but their insurance won’t cover it,” Rao said.

> Read: Irritable Bowel Syndrome and FODMAP Diet
> Read: What is Biofeedback Therapy?