Practical Aspects of Biofeedback Therapy for Constipation

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Practical aspects of using biofeedback therapy for pelvic floor muscle (PFM) dysfunction to treat symptoms of constipation and fecal incontinence include the technical, therapeutic, behavioral, and the pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. There are several technical systems available, and the advantages of any one device have not been scientifically tested. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. The choice of any one system depends on many factors, including cost

Table 13.2. Rome II diagnostic criteria for a diagnosis of pelvic floor dyssynergia

The patient must satisfy diagnostic criteria for functional constipation (Table 13.1) There must be manometric, EMG, or radiologic evidence for inappropriate contraction or failure to relax the pelvic floor 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.

and the goals of training. A solid-state system is preferable to a water-perfused system because there is no distraction or embarrassment from leakage of fluid, and the patient can be reoriented to a sitting position without adversely affecting calibration. Although this instrumentation is of proven effectiveness, this method is relatively cumbersome, complicated, and expensive. The sEMG instrumentation is widely used, proven effective, and suitable for office use.11,12 Patients are able to remain fully clothed during the session and position changes are easily accomplished to assist with functional maneuvers. The therapeutic component involves the clinician's taking an active role by establishing a rapport with the patient, listening to concerns, reviewing the patient's medical history including current medications as well as over-the-counter and herbal preparations, reviewing bowel and bladder habits, educating the patient, and interpreting data.

Clinicians must have a complete understanding of bowel and bladder functioning considering the coexistence of multifactorial concomitant PFM dysfunction. In a patient with symptoms of urinary stress incontinence, noc-turia, and difficulty voiding, Figure 13.1 shows the dysfunctional voiding pattern on the cys-tometrogram (CMG). The increased sEMG activity is indicative of outlet obstruction, inhibiting the detrusor contraction, thus requiring excessive straining by increasing intraabdominal pressure to empty the bladder. This consequently produces a dysfunctional defecation pattern and contributes to symptoms of constipation. Chronic straining with stool is another source of pelvic floor muscle denervation that contributes to pelvic floor muscle weakness and

Increased EMG activity

Interrupted flow Detrusor Inhibition

Increased vesical, abdominal & urethral pressures

Figure 13.1. Voiding phase cystometrogram (CMG) recording.

incontinence.13 Patients with fecal incontinence may complain of multiple daily bowel movements and a feeling of incomplete evacuation resulting in postdefecation seepage.9 Many patients who present with constipation frequently have symptoms of urinary incontinence. Due to the coexistence of concomitant multifac-torial PFM dysfunction associated with weak PFM and outlet obstruction, it is difficult to offer a specific standard biofeedback therapy protocol that is beneficial for all patients. Therefore, the clinician must address all bowel and bladder symptoms and develop an individualized program for each patient with progressive realistic goals. The behavioral component is aimed toward systematic changes in the patient's behavior to influence bowel and bladder function. Operant conditioning utilizing trial and error as an essential part of learning is merely one aspect of the learning process. Treatment is aimed at shaping the patient's responses toward a normal model by gradually modifying the patient's responses through positive reinforcement of successive approximations to the ideal response.9 As a behavioral program, the patient's active participation is paramount in achieving subjective treatment goals, which include symptom improvement, quality of life improvement, and patient satisfaction. The PMR component involves designing an exercise program suitable for each patient to achieve the ultimate goal of efficient pelvic floor muscle function (Table 13.3).

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Constipation Prescription

Constipation Prescription

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