Biofeedback, which involves patient re-education, can be used to treat bowel dysfunction for whichfirst line measures have proved ineffective
Jennie Burch MSc, BSc, RN, is enhanced recovery nurse facilitator; Brigitte Collins MSc, BSc, RN, is lead biofeedback nurse specialist, both at St Mark’s Hospital.
Burch J (2010) Using biofeedback to treat constipation, faecal incontinence and other bowel disorders Nursing Times; 106: early online publication.
Biofeedback is a behavioural therapy used to treat people with bowel dysfunction such as constipation or faecal incontinence, which do not respond to standard treatment. This article highlights how biofeedback therapy is used to treat these problems and improve patients’ quality of life.
Keywords Biofeedback therapy, gastrointestinal, constipation, faecal incontinence
- This article has been double-blind peer reviewed
- Biofeedback is a behavioural therapy for bowel dysfunction
- It is used to retrain the bowel
- Biofeedback can be beneficial for people with constipation and faecal incontinence
Biofeedback is a behavioural therapy offering a non-surgical treatment option for patients with bowel dysfunction including faecal incontinence and constipation.
Faecal incontinence is defined as the involuntary or inappropriate passage of liquid or solid stool (Chelvanayagam and Norton, 1999) and affects between 1-10% of the adult population, with 0.5-10% of adults experiencing regular episodes according to the National Institute for Health and Clinical Excellence (2007). It is a distressing and demoralising condition, resulting in both physical and psychological problems including social restrictions, loss of self-esteem, altered body image and loss of skin integrity (Boyd-Carson, 2003) all of which detrimentally affects quality of life (Norton, 1997; Rothbarth et al, 2001).
Constipation is one of the most common digestive complaints and affects 3-5% of the population depending on which definition is used (Muller-Lissner et al, 2005). The Department of Health (2000) has estimated that £46 million is spent each year in England on laxatives.
When patients do not respond to conservative measures such as dietary fibre, fluid intake and are resistant to laxatives, biofeedback is recommended as a first line non-invasive treatment for those with faecal incontinence, constipation and evacuatory disorders (Storrie, 1997).
Studies in adults suggest that biofeedback for bowel dysfunction is effective and shows improvement for approximately 70% of patients and these patients may potentially have long term benefits](Norton, 2008; Ryn et al, 2000) Norton (2008) However, the effectiveness varies considerably between patients.
What is biofeedback?
The theoretical basis for biofeedback is ‘learning through reinforcement’ or ‘operant conditioning’ techniques (Norton, 2008). It is classed as a re-education tool, in which information concerning a normally subconscious physiological function is relayed to patients and they are actively involved in learning to change this function (Horton, 2004). Biofeedback therapy is used in bowel and muscle retraining to normalise patterns of bowel function and lessen gastrointestinal symptoms caused by functional bowel disorders, such faecal incontinence.
Methods of biofeedback therapy can vary considerably between centres including the numbers of sessions provided and frequency of these sessions. There is no evidence to suggest that one treatment regime is more effective than another. For the purpose of this article the authors will focus on the biofeedback therapy offered from a tertiary centre at St Mark’s Hospital, Harrow.
The biofeedback service at St Mark’s Hospital is a nurse led service that has the support of an extensive multi-disciplinary team. The biofeedback team is made up of six members: a nurse consultant, a lead nurse, three clinical nurse specialists and a physiotherapist.
Biofeedback therapy is an outpatient service and patients are seen for up to four or five sessions at four to six weekly intervals with the same therapist. The initial appointment is for approximately 60 minutes with subsequent follow up appointments of 30 to 40 minutes. The aim of biofeedback therapy is for the patient to improve and take control of their bowel function. (See box 1 for types of patients usually seen by the service.)
Box 1. Types of patients usually seen by biofeedback service at St Mark’s Hospital.
- Women with problems such as obstetric injury;
- People with:
- Idiopathic constipation;
- Evacuation disorder;
- Ileo-anal pouch;
- Solitary rectal ulcer syndrome;
- Idiopathic megarectum.
Many of the patients seen at St Mark’s have bowel symptoms and problems for many years despite repeated visits to their GP, hospital and numerous treatments.
The physiology unit has developed a biofeedback programme for faecal incontinence and constipation that advocates an holistic, individual package of care incorporating many nursing components (see Box 2.)
Box 2. Nursing components of a biofeedback programme
- History and symptom assessment;
- Patient teaching/education;
- Bowel and muscle training;
- Dietary modification/support;
- Emotional support;
- Behavioural therapy;
- Psychological support;
- Electrical stimulation;
- Rectal irrigation (Norton and Chelvanaygam, 2001; Duncan et al, 2003).
Biofeedback therapy tests
Anorectal physiology tests and endoanal ultrasound are usually carried out for patients with faecal incontinence. Anorectal physiology involves a range of tests to assess the sensation and function of the ano-rectum (Nicholls, 2004). Endoanal ultrasound provides a 360 degree image of the anal canal (Williams, 2004) and shows the structure of the internal anal sphincter and external sphincter, necessary for faecal continence.
It is useful for patients to complete a bowel symptom questionnaire to bring to their first session, such as the validated questionnaire developed by Cotterill et al (2008). This introduces patients to the terms used during the initial assessment and provides an opportunity for them to reflect on their bowel symptoms and quality of life.
For constipation/evacuatory disorders, transit studies and/or defaecating proctograms are performed. A transit study involves the patient ingesting six capsules, two each day for three days, each capsule contains ten radio opaque markers. The capsules dissolve in the stomach and the radio opaque markers are dispersed in the gastrointestinal tract. An x-ray is performed six days after the first set of capsules were taken. This x-ray will provide information on the time it takes for food to reach the large bowel indicating normal, slow transit time or evacuatory disorder. (These are defined in Box 3.)
Box 3. Transit studies definitions
Slow transit: More than four of day one markers, more than six of day two markers and 12 or more of day three markers scattered throughout the colon.
Normal transit: No markers present or less than those seen in slow transit.
Evacuatory disorder: This occurs when markers remain in the rectum with a normal transit.
A defaecating proctogram is a barium study and requires thick barium paste to be inserted into the rectum via a rectal tube. An x-ray is taken with the patient sitting on a commode and attempting to expel the paste. This helps to evaluate rectal expulsion as well as providing information on the structure and function of the pelvic floor, including the presence of rectocele, perineal descent, rectal prolapse and intussusseption (enfolding of one portion of the intestine within another).
Biofeedback therapy for constipation
Biofeedback is an individualised package of care and begins with a comprehensive bowel assessment to identify patients’ symptoms and problems as well as their concerns and anxieties. (The components are listed in Box 4.)
Box 4. Components of bowel assessment
- Usual stool consistency;
- Usual stool frequency;
- Pain associated with bowel motions;
- Presence of blood and/or mucus;
- Evacuation problems;
- Past medical history;
- Toilet access issues;
- Diet and fluid intake;
- Medication, including over the counter medications;
- Physical examination.
Source: Horton (2004)
The initial session incorporates an account of biofeedback, the aim of the programme and outlines the commitment and active participation required by patients (Duncan et al 2003).
Patients are often unfamiliar with the structure and function of the digestive tract and what happens to ingested food. The educational aspect of biofeedback therapy involves a discussion about normal colonic function and the defaecatory process with the aid of diagrams and models. This addresses any myths and erroneous beliefs the patients have about their bowel problem.
Consideration should be given to the effect of bowel dysfunction on quality of life, as well as patients expectations of therapy. This ensures that realistic goals are set and an individualised package of care planned.
It is important to explain any test results. Patients with ‘slow transit’ need to understand their bowel function is slow and not a result of a bowel abnormality. Dietary support is offered, particularly when an increase of insoluble fibres,such as bran has been recommended in the past as a way of improving bowel function. There is no doubt that an intake of insoluble fibres increases stool bulk, frequency and softensstool consistency (Fernandez-Banares, 2006). However, an increase in these fibres for people with slow transit can aggravate symptoms of bloating (Muller-Lissner et al, 2005). It is therefore recommended that patients with slow transit reduce intake of insoluble fibre in an attempt to relieve symptoms (Wald, 2007). It should be noted that sources of soluble fibre can be found in fruit and vegetables and help to maintain a healthy diet (Horton, 2004).
Bowel and muscle retraining
The biofeedback programme also concentrates on defaecatory incoordination. This necessitates assessing for poor propulsion and for paradoxical contraction.
Poor propulsion occurs when patients strain and hold their breath with tension in the upper body during defeacation. This prevents an effective bowel movement and can cause other anorectal conditions, such as haemorrhoids (Horton, 2004). Paradoxical contraction occur when the external sphincter is contracted instead of relaxed during defeacation. Evacuation is made more difficult and can lead to retrograde (reverse) peristalsis, which may initiate slower transit (Klauser et al, 1990).
Biofeedback therapists are able to assess bowel co-ordination by inserting a deflated balloon into the rectum and inflating the balloon with 50ml of air. This provides the sensation of a full rectum and the need to defaecate. The therapist monitors patients’ abdominal movements, relaxation and breathing during the attempt to expel the balloon. Many patients demonstrate defaecatory inco-ordination and are taught evacuation techniques. Leaflets for this technique (named the brace exercise) can be found at tinyurl.com/brace-leaflet
An individual home programme is planned, which includes retraining the bowel by teaching new skills or strategies to develop a routine and predictable schedule for evacuation. Additionally patients are taught to sit on the toilet with feet raised on a stool, leaning forward with their arms on their lap and their shoulders relaxed. This provides an anatomically improved pathway for stool to be expelled.
Patients are asked to adjust unusual patterns of behaviour to improve their bowel function, for example not eating to avoid faecal incontinence. This is sometimes difficult, especially when behaviour has been a pattern for many years. Support and guidance from the same therapist can improve progress (Duncan et al, 2003).
There is evidence that psychological disturbance and childhood abuse is associated with bowel dysfunction (Drossman et al,1990; Longstreth et al, 2006). Psychological issues may be divulged by patients during the biofeedback sessions and it is useful to have access to a psychological medicine team. At St Mark’s Hospital referrals can be made to the consultant psychiatrist and sessions with the psychological medicine team run simultaneously with the biofeedback therapy sessions, addressing both physical and psychological issues.
If biofeedback therapy does not improve bowel symptoms for the patient, the therapist may consider transanal irrigation to manage constipation and faecal incontinence. Irrigation is a unique way of assisting the evacuation of faeces from the bowel by introducing warm tap water/enemas through a rectal balloon catheter into the colon via the anus (Gardiner, 2009). This enables emptying of water and stool from the descending colon.
Biofeedback therapy for faecal incontinence
As with constipation, patients presenting with faecal incontinence require a full and comprehensive assessment, which will include an anal and rectal examination.
Other factors considered in biofeedback therapy for this group of patients include:
Patient education: Verbal and written information should be provided about normal gut function and the reason for their symptoms (Norton and Kamm, 1999).
Emotional support: Sufficient time needs to be spent with patients so that feelings and emotions can be explored.
Dietary modification: A reduction in fibre may be advised, especially if intake is high and creating loose/diarrhoea type stools. It is also important to highlight that other types of foods and drinks such as excess caffeine and alcohol may contribute to bowel symptoms. Lactose intolerance and undiagnosed coeliac disease should also be considered (Norton 2008).
Anal sphincter exercises: Anal sphincter assessment can be carried out by a digital rectal examination and can be computer assisted. Exercises are based around patients’ assessments and written leaflets should be adaptedto their individual needs. Leaflets on sphincter exercises can be found at tinyurl.com/biofeedback-patient-info.
Urge resistance: Patients with faecal urgency can benefit from a gradual programme of resisting the urge to defecate using a ‘holding on’ programme. This can be combined in the biofeedback therapy appointments with rectal balloon distension.
Electrical stimulation: The NeuroTrac Continence device, a neuromuscular stimulator, with the Anuform, a intra-anal electrode can be used in faecal incontinence. Electrical stimulation initiates an involuntary contraction of the anal sphincters via an anal plug electrode inserted into the anal canal (Norton 2004). Therapist needs to be familiar with using electrical stimulation. Patients with faecal incontinence that find it difficult to perform sphincter exercises may benefit from electrical stimulation in conjunction with sphincter exercises.
Products for management
Therapists working with biofeedback need to be familiar with products used to manage faecal incontinence, especially if biofeedback therapy has not helped. These include:
- Anal plugs;
- Products for odour control;
- Skin care products;
- Rectal irrigation.
Biofeedback is a highly effective therapy for people suffering with bowel dysfunction, such as constipation or faecal incontinence. Although the principles can vary between centres, the basic principles are to re-educate the patient and support them through this process. Prior to therapy, investigations must be undertaken, particularly if there are concerns about the cause of any change in bowel habit.
Biofeedback consists of a variety of components including education, bowel and muscle retraining, behavioural therapy and psychological support. There are other options that can assist people with constipation such as rectal irrigation. Nurses should know how biofeedback works, identify when it might assist patients and offer advice on how to access therapy if required.
Boyd-Carson W (2003) Developing a faecal incontinence clinic. Gastrointestinal Nursing; 1: 2, 17-18.
Chelvanayagam S, Norton C(1999) Causes and assessment of faecal incontinence, British Journal ofCommunity Nursing; 4: 1, 28, 30, 32-35.
Collins B, Burch J (2009) Constipation, treatment and biofeedback therapy. British journal of communitynursing; 14: 1, 6-11.
Cotterill N et al (2008) A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Diseases of the colon and rectum; 51: 82-87.
Department of Health (2000) Statistical Bulletin - Prescriptions dispensed in the community, Statistics for 1989 to 1999: England. London: DH
Drossman DA et al (1990) Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of Internal Medicine; 113: 828–833.
Duncan J et al (2003) The role of the nurse in behavioural therapy (biofeedback). Hospital Medicine; 64: 6, 329-332.
Ferandez-Banares F (2006) Nutritional care of the patient with constipation. Best Practice & Research ClinicalGastroenterology; 20: 3, 575-587.
Gardiner A (2009) The application of rectal irrigation in the management of functional bowel disorders. Gastrointestinal nursing; 7: 1, 29-35.
Horton N (2004) Behavioural and Biofeedback Therapy for Evacuation Disorders In: Norton C and Chelvanaygam S (eds) Bowel Continence Nursing. Beaconsfield. Beaconsfield Publishers Ltd.
Klauser AG et al (1990) Behavioural modification of colonic function. Digestive Diseases and Sciences; 35: 10, 1271-1276.
Longstreth GF et al (2006) Functional Bowel disorders. Gastroenterology; 130: 1480–1491.
Muller-Lissner SA et al (2005) Myths and misconceptions about chronic constipation. American Journal ofGastroenterology; 100: 232–242.
National Institute of Clinical Excellence (2007) Management of faecal incontinence in adults: CG49. London: NICE guidance.nice.org.uk/CG49
Nicholls T (2004) Anorectal physiology testing techniques.Gastrointestinal Nursing; 2: 7, 33-40.
Norton C(1997) Faecal incontinence in adults, Nursing Standard; 11: 46, 49-55.
Norton C, Kamm MA (1999) Bowel control: information and practical advice. Beaconsfield: Beaconsfield Publishers.
Norton C, Chelvanaygam S(2001) Methodology of biofeedback for adults with fecal incontinence. Journal ofWound, Ostomy and Continence Nursing; 28: 3, 156-168.
Norton C (2004) Behavioural management of faecal incontinence in adults. Gastroenterology; 126: 1, S64-70.
Norton C (2008) Faecal Incontinence and Biofeedback Therapy Gastroenterology Clinics of North America; 37: 3, 587-604.
Rothbarth Jet al (2001) What is the impact of faecal incontinence on quality of life? Diseases of the Colon andRectum; 44: 1, 67-71.
Ryn A et al (2000) Long term results of electromyographic biofeedback training for fecal incontinence. Diseasesof the Colon and Rectum; 43: 9, 1262-1266.
Storrie JB (1997) Biofeedback: a first-line treatment for idiopathicconstipation. British Journal of Nursing; 6: 3, 152-8.
Wald A (2007) Chronic constipation, advances in management. Neurogastroenterology and Motility; 19: 1, 4-10.
Williams A (2004) In: Norton C and Chelvanayagam S (eds) Radiographic Investigations. Bowel continencenursing. Beaconsfield. Beaconsfield Publishers Ltd.