|564||Long-Term Study on the Effects of Visual Biofeedback and Muscle Training as a Therapeutic Modality in Pelvic Floor Dyssynergia and Slow-Transit Constipation [2004년 1월 DCR]||2011-12-23||1961|
Edda Battaglia, M.D.,1 Anna Maria Serra, M.D.,1 Giuseppina Buonafede, M.D.,1 Luca Dughera, M.D.,1 Fabio Chistolini, M.D.,2 Antonio Morelli, M.D.,2 Giorgio Emanuelli, M.D.,1 Gabrio Bassotti, M.D., Ph.D., F.A.C.G.2
1 Servizio di Endoscopia e Motilità Intestinale, Cattedra di Medicina Interna, Dipartimento di Fisiopatologia Clinica, Università di Torino, Torino, Italy
2 Clinica di Gastroenterologia ed Epatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Perugia, Perugia, Italy
PURPOSE: Biofeedback training has been shown as an effective therapeutic measure in patients with pelvic floor dyssynergia, at least in the short term. Long-term effects have received less attention. Moreover, its effects in patients with slow-transit constipation have been scarcely investigated. This study was designed to assess in an objective way the medium- and long-term effects of biofeedback and muscle training in patients with pelvic floor dyssynergia and slow-transit constipation.
METHODS: Twenty-four patients (14 with pelvic floor dyssynergia and 10 with slow transit) meeting the Rome II criteria for constipation, and unresponsive to conventional treatments, entered the study. Clinical
evaluation and anorectal manometry were performed basally and three months after a cycle of electromyographic biofeedback and muscle training; moreover, a clinical interview was obtained one year after biofeedback. Patients with slow-transit constipation also had colonic transit time reassessed
at one year.
RESULTS: Clinical variables (abdominal pain, straining, number of evacuations/week, use of laxatives)
all significantly improved in both groups at threemonth assessment; anorectal manometric variables remained unchanged, apart from a significant decrease of sensation threshold in the pelvic floor dyssynergia group and of the maximum rectal tolerable volume in the slowtransit constipation group. At one-year control, 50 percent of patients with pelvic floor dyssynergia still maintained a beneficial effect from biofeedback, whereas only 20 percent of those complaining of slow-transit constipation did so. Moreover, the latter displayed no improvement in colonic transit time.
CONCLUSIONS: In our experience, patients with pelvic floor dyssynergia are likely to have continued
benefit from biofeedback training in the time course, whereas its effects on slow-transit constipation seems to be maximal in the short-term course.
Chronic constipation is a frequent and often disabling symptom. Constipated patients are usually classified according to radiopaque markers transit (normal and slow-transit constipation). Obstructive
defecation may be observed in approximately 50 percent of patients complaining of chronic constipation
with pelvic floor dyssynergia (PFD) as the most common cause of disordered defecation.
Pelvic floor dyssynergia, thought to be secondary to maladaptive learning, muscles during attempts to defecate, which impedes the outflow of feces. No general agreement exists about diagnostic requirements for this functional disorder, and even its clinical significance is still matter of controversy.
Patients with PFD often are unresponsive to conventional therapeutic measures, and in recent years there had been an increased interest in the use of biofeedback techniques that teach to relax pelvic floor muscles during attempted defecation.
Because approximately two-thirds of PFD patients benefit from biofeedback, this often is regarded as
the treatment of choice for this problem. However, there is evidence that some patients with slowtransit
constipation (STC) also may benefit from this approach, although data on this issue are still scarce. This study was designed to assess objectively the long-term efficacy of biofeedback treatment in
PFD and STC patients.
Electromyographic (EMG) biofeedback was performed by means of an anal plug electrode connected
to an ECL® Elite stimulation-acquisition device (ECL 43400, Chambon sur Lignon, France) that displayed the EMG tracing on a monitor. Once the mode of operation of the equipment had been explained and the electrode had been inserted, the patients were asked to strain as during defecation. When there was an obvious increase on the tracing, instead of the normal decrease, the patients were encouraged to strain without increasing sphincter activity, so that its appearance continued to resemble the resting trace.
Muscular Coordination Training
Muscular coordination training was performed according to a previously published method.19 The patients lay on their side with the knees partly flexed. A lubricated balloon attached to a catheter was inserted into the rectum and inflated with 50 ml of air; the patients were then asked to contract the anal canal and note the sensation. Also, they were taught to direct propulsive force into the pelvis by taking a deep breath, contracting the upper abdominal and diaphragmatic muscles, and simultaneously relaxing and protruding the lower abdomen: a visible protrusion of the latter indicated a correct performance. Moreover, the patients were asked to try and expel the balloon without developing any sense of contraction in the anal region while contracting the abdominal muscles as already practiced. Relaxation of the pelvic floor and effective abdominal straining were indicated by downward movement and passage of the balloon.