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Before anorectal manometric evaluation, bowel preparation was performed by 2 pills of dulcorax suppository. Anorectal manometry was performed using the water-perfusion technique with an 8-channel Micro Tip catheter Medtronic connected to a perfusion pump in the left-lateral position. The physiological parameters included the anal canal resting pressure, squeezing pressure, compliance, defecation index, resting and squeezing vectogram, and rectoanal inhibitory reflex. Rectal sensation was assessed by the inflation of a latex balloon with an air flow of 1 mL per second, and the threshold volumes for the first minimal sensation, desire to defecate, urge, and maximal tolerance were determined.

The balloon expulsion test was carried out with 50 mL water filled balloon in the following order: the catheter was lubricated and inserted to the rectum, and then the balloon was filled with a 50 mL of water at room temperature.

Anxiety, panic attacks and depression – Clinical Efficacy of Biofeedback Therapy

The patients were instructed to sit on a commode chair in a usual defecation position and to pass out the balloon. After waiting for 5 minutes, patients who could not pass the balloon across the anal canal were considered to have failed the balloon expulsion test. The subjects ingested one capsule containing 20 radio-opaque markers in the morning at hour intervals for three consecutive days; 2 simple abdominal radiographs in the supine position were obtained on day 4 and day 7. Localization of the radio-opaque markers was determined by identifying the relations to landmarks of bony structure.

The markers were counted by one experienced gastrointestinal radiologist K. Twenty-two patients were evaluated with a transducer, which was protected by a rigid plastic anal cone, encased in a disposable condom, and inserted with the aid of lubricant.

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This examination was carried out in the left-lateral position, without anorectal preparation. The IAS was defined as a homogenous, hypoechoic circular band that followed the mucosa and submucosa of the anal canal. Sphincter integrity was also determined by slow motion of the probe through the canal. The anal cushion and IAS thickness were determined in the middle anal canal in the ventral, dorsal, left and right lateral sphincter directions, as shown by the electronic cursor on the monitor.

Electrodes were attached to the lower abdomen and acryl plug was inserted into the anal canal. The patient watched a computer monitor displaying amplified, filtered EMG activity.

How Biofeedback for anxiety works

The visual feedback was provided by observing changes in pressure activity on the computer monitor. Biofeedback therapy was planned for total of 10 sessions with 3 sessions per week during the first 2 weeks and 4 sessions during the last week. Sixty-minute biofeedback training session was performed at first and minute session was performed from the second session. Each biofeedback training session was performed while the patient covered with a sheet and sitting on a chair to simulate defecation postures.

In the biofeedback session for constipation, the patient was instructed to relax, squeeze, or strain gently for a series of second trials. The therapist explained the appropriate EMG feature and therapeutic target. In the biofeedback session for fecal incontinence, the patient was instructed to squeeze and relax the anal sphincters repeatedly along with observing changes in pressure activity on a monitor screen. All patients were trained to perform pelvic exercise, modulate the habits of defecation, and modify the diet by verbal or video instructions during biofeedback sessions.

The short-term clinical efficacy was measured immediately after the completion of biofeedback therapy and long-term efficacy was assessed according to the final telephone interview.

Efficacy - AAPB

Then, the statistical analysis was performed by 2 groups: responder with fair or major subgroup and non-responder with none or mild subgroup. Chi-square and Mann-Whitney U tests were used according to categorical or numeric data. A general linear model was used to compare the differences of anorectal function parameters between 2 examinations performed before and after biofeedback therapy. A p-value of less than 0.


Total of 64 patients were enrolled; 25 patients had constipation The mean age was There were more males The bowel movement frequency was 2. The mean follow-up period was Among 9 patients who showed major or fair improvements responder group , 8 patients Among 39 incontinence patients, improvements of incontinence after completion of biofeedback therapy are as follows: major in 6 patients Among 11 patients who showed major or fair improvements responder group , all maintained the symptom improvements through the long-term follow-up periods.

The average number of sessions for biofeedback therapy was 6. No significant difference was observed among the responder group in regard to the frequency of biofeedback sessions in both the constipation and incontinence patients. Analysis was performed between the responder and non-responder group in either constipation or incontinence group.

In the constipation group, no significant differences were found between the responder and non-responder group at baseline with regard to demographic variables such as age, symptom duration, and bowel frequency Table 2. There were no differences in the minimal volume, urgent volume and critical volume in measuring the rectal sensory threshold, while the desire to defecate volume was smaller in the responder group. No differences in colon transit time and balloon expulsion test before biofeedback therapy were noted Table 3. In the fecal incontinence group, there were no significant differences between the responder and non-responder group with regard to the physiological parameters; with the exception on the squeezing pressure before biofeedback therapy Table 4.

Follow-up anorectal manometry test was performed in 3 patients of the constipation group and 13 patients of the incontinence group after completion of biofeedback therapy. Adequate analysis for the physiological parameters before and after biofeedback therapy was not able in the constipation group due to the small sample size. In the incontinence group, the squeezing pressure increased significantly after biofeedback therapy in the responder group as opposed to the non-responder group.

There were no significant differences in the resting pressure and minimal sensory volume before and after biofeedback therapy Table 5. For the incontinence group, the status of anal sphincters was evaluated by transanal ultrasound in 27 patients. Sixteen patients Among 16 patients with normal anal sphincters, 10 patients Biofeedback therapy has been reported to be an effective treatment for functional anorectal disorders such as functional constipation and functional fecal incontinence over the past few decades.

However, there continues to be controversies regarding its efficacy. First, most of the clinical findings were found to be based on the uncontrolled studies. In addition, many of the studies had methodological limitations, such as the differences in the criteria used to define successful outcome, the heterogeneity of the participants studied, and the different variables considered during the assessments.

Furthermore, some studies did not show biofeedback therapy to be more effective than conservative treatments especially in patients with fecal incontinence 22 , 23 and childhood functional constipation. As biofeedback therapy is a relatively inexpensive and non-invasive modality, it could be considered as the first-line therapy in patients with refractory anorectal disorders when its efficacy is predicted to be maintained for a long time interval.

Constipation could be classified into normal-transit constipation, pelvic floor dyssynergia, slow-transit constipation, and the mixed type according to the results of physiological testing. This disorder, which has also been called as anismus, an outlet obstruction or spastic pelvic floor syndrome, is a type of constipation characterized by a failure to relax the puborectalis muscle, the external and internal anal sphincter muscle during the straining for defecation.

In recent controlled studies, Chiarioni et al. Biofeedback therapy was more effective than conservative treatments or sham feedback treatment in patients with pelvic floor dyssyndergia.

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Furthermore, some studies reported the effectiveness of biofeedback therapy for slow-transit constipation, 11 , 12 which was shown by the improvement of cerebral cortex activity controlling colon motility. The lower outcome of biofeedback therapy just after the completion of biofeedback therapy may have originated from the broad category of participants including those with slow-transit constipation. Furthermore, defecation index, which is specific for pelvic floor dyssynergia, 26 was significantly lower in the non-responder group.

Again these results could be due to the broad indication of biofeedback therapy with the relatively old participants in our study.

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Several studies have evaluated the variables associated with successful outcome. Other investigators have suggested milder constipation, less frequent abdominal pain, digital facilitation, slow transit, and the defecation index to be associated with successful outcome. But not a common specific variable emerged when a critical review was performed. In other words, the non-responder group showed higher minimal volume, desire to defecate volume, urgent volume, and critical volume than the responder group and the difference in desire to defecate volume was statistically significant. Furthermore, similar trend was observed in the follow-up anorectal manometry test after completion of biofeedback therapy.

Urgent volume after biofeedback therapy was statistically higher in the non-responder group mL vs. Rectal hyposensitivity is associated not only with functional GI disorders but also with the response to biofeedback therapy, which is more effective in patients with relatively preserved anorectal physiology. Recently, rectal hyposensitivity has been considered as a causal factor for functional GI disorders and some authors are trying therapeutic modalities such as electrical stimulation. The pathophysiological mechanisms of rectal hyposensitivity are not well-known, but some studies have shown the association with diminished rectal perception.

Fecal incontinence is defined as a recurrent uncontrolled passage of fecal material which presents with a social as well as a personal hygienic problem. A few studies showed biofeedback therapy to be selectively effective in patients who were initially considered for surgery. Out of 6 patients showing the thinning, 3 patients responded to biofeedback therapy and among 5 patients showing the defect, only one patient responded to biofeedback therapy.

The generally low response rate of biofeedback therapy may lead to surgical modality, but patients who do not have severe damage could be considered as candidates for biofeedback therapy. Demographic features of fecal incontinence are more common in women than men and increase with age in adults, probably due to the pelvic changes and trauma associated with childbirth. Although biofeedback therapy has been reported to be an effective treatment for fecal incontinence for over the past 30 years, the studies performed are lacking in adequately controlled data.

Nocturnal bruxism is the clenching, bracing, grinding or gnashing of the teeth and jaws during sleep. A team at The Turner Dental Hospital, Manchester, in the United Kingdom, investigated the effect of biofeedback therapy on this condition. Eleven of the participants experienced a reduction in headaches and jaw-muscle discomfort on waking up in the morning.

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The study authors concluded: "The use of biofeedback could reduce the level of parafunctional activity and bring about meaningful symptomatic improvement. A person with apraxia of speech finds it hard to say what they want to say correctly and consistently.

It is due to a problem in the brain, not the speech muscles. Researchers at Haskins Laboratories in Connecticut looked at the effectiveness of a treatment program that included ultrasound biofeedback for six children with childhood apraxia of speech CAS , who had persisting speech sound errors.

After 18 treatment sessions, the authors concluded that "a treatment program including ultrasound biofeedback is a viable option for improving speech sound accuracy in children with persisting errors associated with CAS. Sports psychologist Timothy Harkness used neurofeedback training to help Abhinav Bindra, who won the gold medal in the metres air rifle event at the Beijing Olympics. Article last updated by Yvette Brazier on Wed 8 August All references are available in the References tab.

Biofeedback and relaxation therapy. Biofeedback therapy for Raynaud's disease symptoms. Chiarioni, G. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Dedeepya, P. Nirmala, S. Behavioural and physiological outcomes of biofeedback therapy on dental anxiety of children undergoing restorations: a randomised controlled trial.

European Archives of Paedictric Dentistry 15 Friel, P. EEG biofeedback in the treatment of attention deficit hyperactivity disorder. Alternative Medicine Review 2 2 — Gapen, M. A pilot study of neurofeedback for chronic PTSD. Applied Psychophysiology Feedback. Harkness, T. Professional issues: Psykinetics and biofeedback: Abhinav Bindra wins India's first-ever individual gold medal in Beijing Olympics.

Applied Psychophysiology and biofeedback. Krystal, J.