How to cite this article: Guerra-Mora JR, Buenrostro-Acebes JM, Erciga-Vergara N, Zubieta-O'Farrill G, Castillo-Calcáneo JD, Mosqueda ME, Monroy-Argumedo M, González-Alvarado C, Villanueva-Saenz E. Biofeedback effectiveness in patients with fecal incontinence. Rev Med Inst Mex Seguro Soc. 2015 Jul-Aug;53(4):472-5.
Received: September 30th 2013
Accepted: October 30th 2014
aHospital Ángeles del Pedregal
bFacultad Mexicana de Medicina, Universidad La Salle
cDepartamento de Neurocirugía, Hospital Central, Sur de Alta Especialidad, Petróleos Mexicanos
Distrito Federal, México
Communication with: Eduardo Villanueva-Saenz
Telephone: (55) 5627 7070
Background: Fecal incontinence is defined as an involuntary bowel movement through the anal canal in inadequate time and place. There are different types of therapies for the management of fecal incontinence, being biofeedback therapy one of the most effective techniques. The aim of this study was to evaluate the necessary number of sessions of biofeedback electromyographyc therapy to achieve the maximum sphincteric complex contraction.
Methods: Descriptive, retrospective and longitudinal study. 65 patients with fecal incontinence were included. Weekly electromyographyc biofeedback therapies were applied, with a maximum of 6, in which the sphincteric complex contraction was measured. A two ways Friedman analysis was made to determine the significant differences between the sessions.
Results: A total of 65 patients were evaluated for fecal incontinence. The values for pelvic floor contraction were significantly higher in the third session, and did not show any significant difference in posterior sessions.
Conclusion: The maximum contraction of the sphicnteric complex was achieved in the third weekly biofeedback session, without any significant differences in the posterior sessions.
Keywords: Fecal incontinence; Biofeedback; Electromyography
Fecal incontinence is defined as involuntary leakage of stool through the anus in an inappropriate time and place.1 It affects between 1 to 2% of the general population2 and 2.2% of the population over 65 years of the United States of America.3 It is a disabling condition that impairs the quality of life significantly. The prevalence in men and women is similar; however, the severity tends to be higher in women and with more insidious symptoms.
Fecal incontinence has different etiologies, which can coexist in the same individual. The most common causes and contributing factors are: external and / or internal anal sphincter injury, diarrhea, loss of rectal reservoir, loss of sensation of defecation, constipation or incomplete evacuation, anorectal disease, disability leading to difficulty moving to the bathroom, mental disability to meet social norms of behavior defecation (dementia) and idiopathies.4
The pathophysiological mechanism of fecal incontinence is complex despite the simplicity with which doctors refer to it. Proper sphincter complex mechanism requires the ability to discriminate between solid, liquid and gas, allowing voluntary coordinated release.5
The evaluation of fecal incontinence requires an understanding of the complexity of the pelvic floor musculature, innervation, function and mechanisms that must be present to ensure continence.
Symptoms of fecal incontinence range from mild to severe, and the management and treatment of this disorder varies widely. Patients may present with incontinence to flatus, liquids or solids. In some patients just knowing that at any place or time an incontinence accident can happen significantly reduces their quality of life and limits their ability to interact socially.6
There are several therapies for the management of fecal incontinence, among which biofeedback therapy stands out for its effectiveness, a term that refers to the use of mechanical and electrical mechanisms that increase the sensitivity of the biological response so that the patient, through trial and error, can improve voluntary control of such response.7 It has been reported that approximately 70% of patients obtained satisfactory results with the use of this technique.4 The critical points of this treatment are the increased somatic sensitivity and improved motor skills, which are the basis of biological self-regulation (biofeedback).8
Biofeedback treatment was proposed 30 years ago by Engel,9 who taught nine patients to improve the ability to voluntarily contract the external anal sphincter during rectal filling, increasing the strength of the sphincter (motor skill training) or increasing the ability of perceive a slight rectal distension (discrimination training), or a combination of the two. No adverse effects were reported and it was well accepted.6
Biofeedback therapy means patient biological signals are transformed into visual and auditory signals to provide a training guide according to the physiological activities and to subsequently promote functional recovery.10
There are different types of biofeedback, with measurement of voluntary contraction using intra-anal electromyography (EMG), and anorectal manometry being the main techniques used. Intra-anal EMG is performed with the patient sitting with an intra-anal sensor connected to a computer, this being the most physiological technique. On the other hand, the gauge technique is performed with the patient in left lateral decubitus, using a rectal probe with balloon.5
Most studies concerning the use of biofeedback are carried out with the gauge technique, although patients are placed in a non-physiological position for normal defecation. It was found that 2/3 patients showed a 75% decrease of fecal incontinence episodes, however symptoms of incontinence only disappeared in 50% of these.11
The following predictors relate negatively with biofeedback: Severe anatomical damage to the sphincter complex,12 nerve damage,13 and low basal pressure of the internal anal sphincter.14
Among previous studies the duration of therapy varies (30-60 min), as does the interval between sessions, ranging from one to two a week, and the number of sessions, which influence the results and the effectiveness of the use of biofeedback therapy for fecal incontinence. The number of sessions required for maximum contraction of sphincter complex in patients with fecal incontinence is unknown.
The aim of this study was to evaluate the number of sessions of therapy with the electromyographic biofeedback technique required to achieve the maximum contraction of the pelvic muscles, in order to achieve better compliance with treatment and a decrease in unnecessary expense for both the patient and the institution providing the treatment.
A descriptive, retrospective and longitudinal study in the Pelvic Floor Diagnostic and Rehabilitation Unit of the Digestive Physiology Clinic at Hospital Angeles del Pedregal. All patients with a diagnosis of isolated fecal incontinence in the period from April 1, 2008 to November 30, 2012 were included, but patients who did not attend at least 3 consecutive sessions, and patients with neurological or mental illnesses were excluded.
Upon admission, a baseline intra-anal EMG is conducted, subsequently biofeedback sessions were conducted each week with a maximum of six. The equipment used was the EMG data acquisition module SRS Regain (SRS medical systems, Redmont WA) with Muscle Works software (SRS medical systems, Redmont WA), and Perry ceramic intra-anal sensor (SRS medical systems, Redmont WA) (Figure 1). The initial session lasts an hour, the anatomy and physiology of the pelvic floor was explained to the patient in detail, then the patient places the intra-anal sensor, which receives electrical signals and converts them into visual signals on a monitor placed by a data receiver module, showing the user the contraction of the pelvic floor in real time. During the session the patient remains clothed and seated comfortably; they are asked to perform 6 fast contractions in order to determine muscle strength or degree of activity of the rapid response fibers (flicks), and finally performs six sustained contractions of 10 seconds (holds) to measure muscle tone and strength. Once the assessment protocol is completed, the results are explained to the patient, based on which a customized training program is performed by a therapist licensed in the pelvic floor by the Cleveland Clinic in Fort Lauderdale, Florida, USA, which can be modified according to the weekly patient outcomes. Each session lasts 35-50 minutes depending on the performance of the patient and questions that may arise, establishing a program of work at home.
Figure 1 shows the data acquisition module, the software used, and the intra-anal sensor, from right to left
The results are expressed as mean ± SD and range, a two-way Friedman analysis of variance was performed by ranges of related samples to determine significant differences between the different values of sphincter complex contraction during the biofeedback treatment sessions; a value of p <0.05 was taken as statistically significant. Statistical analysis was performed using the program SPSS version 20.0.
We evaluated a total of 65 patients with fecal incontinence in the aforementioned period, 4 patients were excluded for not meeting the minimum 3 sessions of consecutive treatment, and 2 because of neurological or mental illness, 59 study subjects being included, of which 41 ( 69.4%) were female and 19 (32.2%) male. Mean number of biofeedback sessions performed per patient was 3.84 ± 1.33. The values of pelvic floor contraction (Table I) were statistically significantly higher in the third session of biofeedback therapy, showing no significant improvement in subsequent sessions (Figure 2).
|Table I Values of EMG in the various biofeedback treatment sessions|
|EMG = electromyography, mV = Millivolt|
Figure 2 Means +/- SD of the voltage obtained through EMG of sphincter complex in patients undergoing biofeedback therapy throughout the various sessions. There was a statistically significant difference at baseline * (p = 0.008) and session 1 ** (p = 0.022) relative to session 3, *** according to Friedman analysis of variance
There are no reports in the literature that mention the number of sessions with electromyographic biofeedback technique or gauge necessary to achieve greater sphincter complex contractility in patients with fecal incontinence. In our study we conducted consecutive weekly biofeedback therapy, noting that after the third treatment session there was no significant increase in contractility of the sphincter complex, however the maximum force achieved is maintained, which is one of the goals of the rehabilitation. There is evidence that up to 50% of patients who did 3 sessions of biofeedback no longer have fecal incontinence, 15 however it is unknown the number of sessions required to achieve maximum benefit in the pelvic muscles. In 10 sessions 50% of patients had clinical improvement and gauge improvement, but no mention is made of the session in which the best results were achieved.16
In our study we excluded patients with mental illness due to poor results presented with biofeedback therapy given the lack of proper performance of pelvic floor exercises at home.
It is interesting to note that more than three sessions does not increase sphincter complex contractility, it even decreases insignificantly, which is useful for saving resources and patient comfort.
No clinical data of patients were obtained and no improvement in quality of life was assessed, so prospective studies need to be developed that take into account clinical data and correlate them with sphincter complex contractility.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.