Biofeedback Treatment Research Articles

Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice.

We aimed to evaluate the prevalence of psychological impairment in patients with rectal evacuation disorders and the influence of psychological disorder on the early outcome of behavioral treatment. We retrospectively reviewed the medical records of patients with rectal evacuation disorders referred for biofeedback retraining at a tertiary referral center. The psychological disorder was classified using the DSM IV criteria. Outcome of biofeedback treatment of evacuation at 2 wk was based on symptoms or on the ability to spontaneously expel a balloon placed in the rectum. Improvements in the groups without versus with a psychological disorder or an eating disorder were compared by Fisher's exact test. In the 60 patients (55 women; 5 men; mean age, 38 yr), psychological disorders were identified in 39 (65%); also noted were eating disorder (n = 5), rumination syndrome (n = 3), pain disorder (n = 6), anxiety-depression (n = 10), a combination of depression and pain disorder (n = 3), and a combination of eating disorder with anxiety-depression and pain disorder (n = 12). There was an association between psychological status and outcome at 2 wk of behavioral treatment for evacuation disorder (p = 0.03). The coexistence of eating disorder and psychological disorder resulted in an unfavorable outcome (p = 0.02), compared with those without psychological disorder. Psychological impairment was identified in 65% of the patients with evacuation disorder and constipation in a tertiary care practice, and has a significant negative impact on the outcome of behavioral treatment. These data reinforce the importance of a multidisciplinary approach in the management of these patients.

Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice

OBJECTIVE: We aimed to evaluate the prevalence of psychological impairment in patients with rectal evacuation disorders and the influence of psychological disorder on the early outcome of behavioral treatment. METHODS: We retrospectively reviewed the medical records of patients with rectal evacuation disorders referred for biofeedback retraining at a tertiary referral center. The psychological disorder was classified using the DSM IV criteria. Outcome of biofeedback treatment of evacuation at 2 wk was based on symptoms or on the ability to spontaneously expel a balloon placed in the rectum. Improvements in the groups without versus with a psychological disorder or an eating disorder were compared by Fisher’s exact test. RESULTS: In the 60 patients (55 women; 5 men; mean age, 38 yr), psychological disorders were identified in 39 (65%); also noted were eating disorder (n = 5), rumination syndrome (n = 3), pain disorder (n = 6), anxiety-depression (n = 10), a combination of depression and pain disorder (n = 3), and a combination of eating disorder with anxiety-depression and pain disorder (n = 12). There was an association between psychological status and outcome at 2 wk of behavioral treatment for evacuation disorder ( p = 0.03). The coexistence of eating disorder and psychological disorder resulted in an unfavorable outcome ( p = 0.02), compared with those without psychological disorder. CONCLUSION: Psychological impairment was identified in 65% of the patients with evacuation disorder and constipation in a tertiary care practice, and has a significant negative impact on the outcome of behavioral treatment. These data reinforce the importance of a multidisciplinary approach in the management of these patients.

Empirically supported treatments in pediatric psychology: constipation and encopresis.

To review the empirical research examining behavioral and medical treatments for constipation and fecal incontinence. Sixty-five articles investigating intervention efficacy were identified and reviewed. Twenty-three of the studies were excluded because they were case studies or were less well-controlled single-case designs. The intervention protocol for each study was identified and coded, with studies employing the same interventions matched and evaluated according to the Chambless criteria. From the literature base to date, no well-established interventions have emerged. However, four probably efficacious treatments and three promising interventions were identified. Two different medical interventions plus positive reinforcement fit the criteria for the probably efficacious category (one with fiber recommendation and one without). Three biofeedback plus medical interventions fit efficacy category criteria: one probably efficacious for constipation with abnormal defecation dynamics (full medical intervention plus biofeedback for paradoxical contraction), and two fit the promising intervention criteria for constipation and abnormal defecation dynamics (full medical intervention plus biofeedback for EAS strengthening, correction of paradoxical contraction and home practice; and biofeedback focused on correction of paradoxical contraction, medical intervention without fiber recommendation, and positive reinforcement). Two extensive behavioral interventions plus medical intervention also met efficacy criteria for constipation plus incontinence (medical intervention without laxative maintenance plus positive reinforcement, dietary education, goal setting, and skills building presented in a small-group format fits criteria for a promising intervention; and positive reinforcement and skills building focused on relaxation of the EAS during defecation, but without biofeedback, plus medical intervention meets the probably efficacious criteria). A discussion of the current weaknesses in this research area follows. Specific recommendations for future research are made including greater clarity in treatment protocol and sample descriptions, reporting cure rates rather than success rates, utilization of adherence checks, and investigation of potential differential outcomes for subgroups of children with constipation and incontinence.

Pelvic floor study in patients with obstructive defecation: influence of biofeedback.

The aim of this study was to evaluate the pathophysiologic abnormalities in patients with obstructive defecation or dyssynergia and to assess the role of biofeedback treatment. Three groups were studied. Group A had 24 patients with obstructive defecation; B, 25 patients with constipation; and C, 22 healthy volunteers. Rectosigmoid segmental transit time of group A was 28.5 hours (SD +/- 13.4); B, 17.2 hours (SD +/- 11.5); and C, 8.5 hours (SD +/- 6.3) (p < 0.05). There was no statistical difference in resting and squeezing anal pressure among the three groups. Anorectal angle at rest revealed no difference among the three groups. At strain, a statistically significant difference between groups A and C (p < 0.05) and a marginal difference between groups A and B was noted. Rectocele of the anterior rectal wall was present at strain in 17/24 patients of group A and 7/22 patients of group C (p < 0.05). Electromyography during strain revealed abnormal contractions of puborectalis muscle and external anal sphincter, in 13 and 14 patients of group A, respectively, which differed from that observed in groups B and C (p < 0.001). Biofeedback treatment was applied with good results in 7 of 11 patients of group A. At six months, constipation relapsed in only one of treated patients. Patients suffering from obstructive defecation seem to have slower rectosigmoid transit time than the others. Defecography shows smaller anorectal angle at strain and rectocele of the anterior rectal wall more often. Abnormal pelvic floor contraction at strain is often noted in anal electromyography. Some of these patients seem to respond favorably to biofeedback treatment.

Age comparisons in acquiring biofeedback control and success in reducing headache pain.

This article presents a review and archival analysis to assess age differences in acquiring biofeedback control and success in treating recurrent headache by using data from 56 studies with either adult (total N = 503) or child (total N = 98) subjects. All studies focused on treating headache with temperature biofeedback (TBF) or electromyographic (EMG) biofeedback. To standardize the varied measures across studies, we calculated each study's percent change scores for biofeedback performance and headache activity. All headache activity scores included assessments of pain intensity. We then calculated subject-weighted means of percent change for biofeedback performance and for headache activity by summing the products of each relevant percent change score and N and then dividing by the total number of subjects contributing to those sums. Results showed that both children and adults reported substantial improvements in headache activity with TBF and EMG biofeedback treatment (Ms ranged from 34% to 81%), but children showed significantly greater improvement than adults. No age differences were found in the acquisition of biofeedback control. Further analyses revealed two additional findings. First, biofeedback control and headache improvement were strongly correlated. Second, headache activity continued to decrease in the weeks following treatment, and this decrease was significantly greater for children than adults.

Blood pressure biofeedback treatment of white-coat hypertension

Objective: The objective of the study was to compare blood pressure (BP) biofeedback treatment (BF) effects between white-coat hypertension and essential hypertension. Methods: Fifteen white-coat hypertensive out-patients and 23 essential hypertensive out-patients were randomly assigned to groups A or B. Subjects in group A underwent BF once a week for a total of four sessions. Those in group B visited the clinic only to measure BP and later underwent the same BF. Results: In group A, BPs of white-coat hypertensives and essential hypertensives were significantly reduced by 22/11 and 14/8 mmHg, respectively. In group B, they were unchanged during the same period but later suppressed by BF. Under BF, pulse and respiratory rates were significantly higher, and elevation of diastolic BP due to mental stress testing was better suppressed in white-coat hypertensives than in essential hypertensives. Conclusion: This treatment was effective in both types of hypertension, and pressor response to stress seems to be important in the differentiated BF effect.

EEG operant conditioning (biofeedback) and traumatic brain injury.

A review is presented of the currently sparse literature about EEG operant conditioning or biofeedback as a treatment to reduce symptomology and patient complaints following a traumatic brain injury. The paper also evaluates the general use of quantitative EEG (QEEG) to assess traumatic brain injury and to facilitate EEG biofeedback treatment. The use of an age matched reference normative QEEG database and QEEG discriminant function are presented as a method to evaluate the nature or neurological basis of a patient's complaints as well as to individualize an efficient and optimal feedback protocol and to help evaluate the efficacy of the biofeedback therapy. Univariate and multivariate statistical issues are discussed, different classes of experimental designs are described and then a "double blind" research study is proposed in an effort to encourage future research in the area of EEG biofeedback for the treatment and rehabilitation of traumatic brain injury.

A Review of EEG Biofeedback Treatment of Anxiety Disorders

Alpha, theta and alpha-theta enhancements are effective treatments of the anxiety disorders (Table 1). Alpha suppression is also effective, but less so (Table 2). Perceived success in carrying out the task plays an important role in clinical improvement. Research is needed to find out how much more effective they are than placebo, and which variables are important for efficacy. Variables needing study are: duration of treatment, type and severity of anxiety, number and type of EEG waveforms used, pretreatment with other kinds of feedback, position and number of electrodes, and presence of concomitant medication.

Behavioural treatment (biofeedback) for constipation following hysterectomy

Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment. Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance. Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups. The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.

A Study of Pelvic Floor Function Pre– and Postradical Prostatectomy Using Clinical Neurourological Investigations, Urodynamics and Electromyography

Objectives: Incontinence after radical prostatectomy is addressed to sphincter damage and/or bladder dysfunction. Taking into account a high cure rate of incontinence by pelvic floor biofeedback treatment, the search for further mechanisms of a complex physiological concept seems feasible.Methods: To characterize pelvic floor function, 18 patients were prospectively evaluated before and after radical prostatectomy by clinical neurourological tests, urodynamics and needle/surface electromyography (EMG).Results: In all patients (mean age 62 years) investigations were completed successfully. The outcomes of neurourological investigations (sacral reflexes, voluntary pelvic floor contraction and relaxation) and needle EMG showed no significant changes in the pre–/postoperative comparison. Only by using surface EMG polygraphy change of activation patterns during pelvic floor contraction (decreased mean and medium frequency) could be found.Conclusion: In patients without preexisting bladder dysfunction and with a basically normal operative and postoperative course, fine motoric changes of pelvic floor function are the main finding. This cannot be explained by a pure anatomical approach. Neurophysiological events, like a barrage of nociceptive information, caused by surgical dissection and an inflammatory reaction due to the healing process, contribute to altered processing within the central nervous system. The appreciation of these mechanisms, well studied in neuroscience and pain research, offers a better understanding of surgery–related short– and longterm morbidity after pelvic surgery, i.e., urinary incontinence and erectile dysfunction.

Blood Pressure Biofeedback Treatment, Organ Damage and Sympathetic Activity in Mild Hypertension

Background: Although biofeedback treatment is reported to be useful for patients with mild hypertension as an adjunct to medication, it is not certain whether the presence of organ damage affects its efficacy. The aim of this study is to clarify the clinical effects of biofeedback on mild hypertension in the absence and presence of organ damage. Methods: Eleven mildly hypertensive outpatients without damage to the heart, brain, retina or kidney (4 men and 7 women), aged 40–65 years, and 11 mildly hypertensive outpatients with target organ damage and matching variables for age, sex and medication were included in this study. They underwent biofeedback treatment once a week for a total of four sessions. Results: As a result of these sessions, mean blood pressures (MBP) in the organ-damage-negative (–) group and in the organ-damage-positive (+) group were significantly reduced by 12 ± 11 and 12 ± 8, respectively. The decrease was still significant 3 months after the treatment in the organ-damage (–) group, whereas no significant change was found 1 or 3 months after the treatment in the organ-damge (+) group. Throughout these sessions, the ratio of low frequency to high frequency of heart rate variance as well as systolic and MBP gradually decreased in each group (p < 0.01); this ratio of heart rate variance was smaller, and the α-wave amplitude on the electroencephalogram was larger in the organ-damage (–) group (p < 0.05). Conclusion: These results suggested that biofeedback intervention may be effective in mild hypertension, especially when the patient is organ damage (–). Sympathetic activity seems to play an important role in the differentiated response.

Outcome of biofeedback for faecal incontinence.

Biofeedback has been reported to improve or eliminate symptoms in approximately 70 per cent of patients with faecal incontinence. However, it is unknown which patients respond in relation to the different symptomatic types of faecal incontinence and the different structural sphincter aetiologies. One hundred consecutive patients (84 women; median age 49 years) who completed biofeedback treatment were prospectively characterized by symptoms and by structural integrity of the internal and external anal sphincters as assessed endosonographically (87 patients). Patients underwent a median of 4 biofeedback sessions. Overall, 43 of the 100 patients regarded themselves as symptomatically cured and 24 improved after treatment. Cure or improvement was experienced by 24 of 30 patients with a structurally normal anal sphincter, by 27 of 46 patients with an external anal sphincter structural defect, and by seven of 11 with an isolated internal anal sphincter defect or atrophy. Thirty-three of 60 patients with urge incontinence alone were symptomatically cured, compared with five of 22 of those with only passive incontinence. Biofeedback retraining is effective in the short term in treating a majority of patients with faecal incontinence. It is most successful in treating urge incontinence, but also helps some patients with passive leakage. Even in patients with structural anal sphincter damage, some symptom improvement or cure is achieved.

A review of randomized clinical trials in tinnitus.

Review reports of randomized clinical trials (RCTs) in tinnitus to identify well-established treatments, promising developments, and opportunities for improvement in this area of clinical research. Literature review of RCTs (1964-1998) identified by MEDLINE and OLD MEDLINE searches and personal files. Studies were compared with the RCT criteria of Guyatt et al. for quality of design, performance, and analysis; "positive" results were critically examined for potential clinical relevance. Sixty-nine RCTs evaluated tocainide and related drugs, carbamazepine, benzodiazepines, tricyclic antidepressants, 16 miscellaneous drugs, psychotherapy, electrical/magnetic stimulation, acupuncture, masking, biofeedback, hypnosis, and miscellaneous other nondrug treatments. No treatment can yet be considered well established in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects. Nonspecific support and counseling are probably helpful, as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants, and electrical stimulation deserve further study. Future tinnitus therapeutic research should emphasize adequate sample size, open trials before RCTs, careful choice of outcome measures, and long-term follow-up.

Biofeedback for anismus: has placebo effect been overlooked?

Multiple uncontrolled studies have concluded that biofeedback is successful in treating anismus. This study's objective was to assess the physiological effects of placebo and biofeedback treatment on patients with anismus and to correlate changes with clinical improvement. Twelve patients with symptoms and electrophysiological findings of anismus were studied. Initial assessment included a detailed history, symptom assessment by linear analogue scales, anorectal manometric and electrophysiological studies, colon transit scintigraphy, and scintigraphic proctography. Patients underwent 5 days of placebo treatment, followed 1 week later by re-assessment of symptoms and physiological studies. Five days of biofeedback was then given followed by another complete re-assessment 1 week later. A final interview was performed 2 months later. All assessments were by an independent observer who was not responsible for the treatments. Seven patients reported an overall improvement in symptoms following placebo treatment. A total of seven patients reported improvement following biofeedback, three of whom had already reported an improvement with placebo. One patient who reported improvement following placebo had worsening of symptoms following biofeedback. The only symptoms or tests which changed more with biofeedback than placebo were anal pressure and electromyographic activity on attempted defaecation in the left lateral position. There was no demonstrable correlation between change in symptoms and change in physiological tests. The scintigraphic 'ejection fraction' of the rectum was unchanged by treatment. Clinical improvement in previous studies may in part be due to placebo effect and observer bias. Improvement with biofeedback may be due to physiological changes which are not detected with conventional anorectal physiological tests.

Biofeedback-assisted relaxation training with brain injured patients in acute stages of recovery

There are few published accounts or empirical studies of biofeedback assisted relaxation training with brain injured patients still in acute stages of recovery. Given the efficacy of biofeedback assisted relaxation training with other medical populations, brain injured patients in acute stages of recovery with anxiety based symptoms may also stand to gain some benefits form this form of treatment. It has yet to be determined, however, if severe cognitive impairment or disorientation contraindicate biofeedback treatment. The cases profiled here tentatively suggest that consideration of biofeed back assisted relaxation training, even for severely cognitively impaired brain injured patients in acute stages of recovery, may be appropriate. Empirical investigations will be needed to determine selection criteria and contraindications for biofeedback treatment in the acute brain injury population.

The Comparison of the Effectiveness of Pelvic Floor Muscle Exercise and Biofeedback Treatment for Stress Incontinence in Korean Women

The Comparison of the Effectiveness of Pelvic Floor Muscle Exercise and Biofeedback Treatment for Stress Incontinence in Korean Women

Neurofeedback treatment of pseudoseizure disorder

Background: Previous research has shown that the suppression of theta wave activity and the enhancement of sensorimotor rhythm (SMR) through electroencephalographic (EEG) biofeedback is an effective treatment for epilepsy. The current research reports the results of EEG biofeedback treatment for patients presenting with seizure behaviors in the absence of eliptiform EEG activity. Methods: In addition to psychotherapy, 3 patients, 2 women and 1 man, were trained, using EEG feedback once per week, to reduce the ratio of theta band to SMR band EEG amplitudes. Results: The results showed that reductions in seizure activity were related to reductions in the theta–SMR ratio. Conclusions: These findings support the view that theta–SMR feedback training, in conjunction with psychotherapy, is an effective adjunctive treatment for pseudoseizure disorder.

Biofeedback treatment of constipation in children

van Ginkel, R.1; Kuiken, S. D.1; van der Plas, R. N.1; Benninga, M. A.1; Büller, H. A.2; Taminiau, J. A.J.M.1 Author Information

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

Biofeedback provides long term benefit for patients with intractable, slow and normal transit constipation

Background—Many patients with idiopathic constipation do not respond to conventional medical treatments. Recently biofeedback has been proposed as an alternative treatment but the long term results, and which patients benefit,...