Biofeedback for Faecal Incontinence and ConstipationBy courtesy of

Christine Norton PhD MA RN

Nurse Consultant (Bowel Control) &

Professor of Gastrointestinal Nursing

St Mark’s Hospital & Kings College

London, United Kingdom

What is “Biofeedback”?

• Whatever you want it to be?• Use of equipment to record or amplify

biological signals normally unnoticed, to enable the individual to alter function or responses

• Huge variety of protocols– 1-28 sessions– Daily-monthly– Few described intervention or used controls

3 main modalities for FI• Strength training: feedback of squeeze increment

to enhance performance of exercises– EMG (surface or intra-anal) (17 studies)– Pressure (water perfused, solid state, air balloon)– Ultrasound (anal or vaginal) (2 studies)

• Increase voluntary squeeze response to rectal distension (co-ordination)

• Rectal balloon: decrease threshold of sensation to rectal filling, or increase threshold for urgency

• Combinations

Systematic review of biofeedback for FI• 46 studies identified in adults in English

• Total of 1364 patients

• 49% no incontinence, 72% cured or improved

• Only one study showed no improvement• Poor outcome measures, no standard

technique (Norton & Kamm, Alimentary Pharmacology & Therapeutics, 2001)

• Now (2006) 65+ case series

Problems with case series

• Publication bias (negative studies not published?)

• We all talk to patients (hopefully)• Known effect of intervening per se (placebo

response is high in functional gut disorders)• Confounding effect of: time, attention, patient

education and understanding, reassurance that symptoms not sinister, advice on diet, titration of medication…etc

• Is it biofeedback that is effective??

Elements of “Biofeedback”

• Nurse / physiotherapist led service• Patient teaching and understanding• Sphincter isolation & exercises (+ home practice)

Strength, endurance, speed of reaction

• Behaviour modification - urge resistance +/- balloon distension & co-ordination

• Diet, caffeine, lifestyle• Practical coping & medication titration• Emotional support• Which are the important elements?(Norton & Chelvanayagam, JWOC Nursing, 2001)