Biofeedback therapy in constipation and fecal incontinence.
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ABSTRACT: This systematic review determines the best known form of biofeedback (BF) and/or electrical stimulation (ES) for the treatment of fecal incontinence in adults and rates the quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation. Attention is given to type, strength, and application mode of the current for ES and to safety. Methods followed the Cochrane Handbook. Randomized controlled trials were included. Studies were searched in The Cochrane Library, MEDLINE, and EMBASE (registration number (PROSPERO): CRD42011001334). BF and/or ES were studied in 13 randomized parallel-group trials. In 12 trials, at least one therapy group received BF alone and/or in combination with ES, while ES alone was evaluated in seven trials. Three (four) trials were rated as of high (moderate) quality. Average current strength was reported in three of seven studies investigating ES; only two studies reached the therapeutic window. No trial showed superiority of control, or of BF alone or of ES alone when compared with BF + ES. Superiority of BF + ES over any monotherapy was demonstrated in several trials. Amplitude-modulated medium-frequency (AM-MF) stimulation, also termed pre-modulated interferential stimulation, combined with BF was superior to both low-frequency ES and BF alone, and 50 % of the patients were continent after 6 months of treatment. Effects increased with treatment duration. Safety reporting was bad, and there are safety issues with some forms of low-frequency ES. There is sufficient evidence for the efficacy of BF plus ES combined in treating fecal incontinence. AM-MF plus BF seems to be the most effective and safe treatment. • The higher the quality of the randomized trial the more likely was a significant difference between treatment groups. • Two times more patients became continent when biofeedback was used instead of a control, such as pelvic floor exercises. • Two times more patients became continent when biofeedback plus electrical stimulation was used instead of biofeedback only. • Low-frequency electrical stimulation can have adverse device effects, and this is in contrast to amplitude-modulated medium-frequency electrical stimulation. • There is high quality evidence that amplitude-modulated medium-frequency electrical stimulation plus electromyography biofeedback is the best second-line treatment for fecal incontinence.International Journal of Colorectal Disease 07/2013; 28(11). · 2.24 Impact Factor
JNM Journal of Neurogastroenterology and Motility
J Neurogastroenterol Motil, Vol. 16 No. 2 April, 2010
ⓒ 2010 The Korean Society of Neurogastroenterology and Motility
J Neurogastroenterol Motil, Vol. 16 No. 2 April, 2010
Biofeedback Therapy in Constipation and Fecal
Seung-Jae Myung, MD, PhD
Division of Gastroenterology, Constipation Clinic, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College
of Medicine, Seoul, Korea
Received: March 13th, 2010
CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work
is properly cited.
*Correspondence: Seung-Jae Myung, MD, PhD
Division of Gastroenterology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea
Tel: +82-2-3010-3917, Fax: +82-2-476-0824, E-mail: firstname.lastname@example.org
Financial support: This work was supported by grants from National Research Foundation of Korea (2009-0083559) and KRIBB Research Initiative
Conflicts of interest: None.
Accepted: March 23rd, 2010
Article Article: The long-term clinical efficacy of biofeedback therapy for patients with constipation or fecal incontinence
(J Neurogastroenterol Motil 2010;16:177-185)
Chronic constipation and incontinence are common symp-
toms especially in western countries.1 However, these problems
are increasing among Asians probably due to the rise in aging
population and westernization of diet. The pathogenesis of con-
stipation varies in patients with colonic transit delay, dyssynergic
defecation, or both, while the cause of incontinence is often weak-
ening or structural defect of anal sphincters.2
Constipated patients may respond either to fiber-fluid sup-
plementation, prokinetics, or judicious use of laxatives. Among
non-responders, outlet obstructive type of dysfunction seems par-
ticularly common; it affects up to 50% of patients with chronic
constipation who are referred to a tertiary care center.3 In patients
with incontinence, biofeedback therapy is the first line treatment
before considering surgery.3
Biofeedback therapy is a learning strategy originating from
psychological learning theories, more specifically from ‘instru-
mental learning’ and ‘operant conditioning.’4 This therapy has
been reported to be effective in constipation and incontinence.
Recently, three randomized controlled trials (RCTs) have been
published between 2006 to 2007 which provide definitive evi-
dence for the efficacy of biofeedback in adults with dyssynergic
defecation.5-7 Biofeedback treatment is also effective in reducing
incontinence in more than two-thirds of patients and is generally
In this issue of Journal of Neurogastroenterology and
Motility, Lee et al. reported the result of biofeedback therapy for
patients with constipation and incontinence in a single center.
Their report indicated unsatisfactory symptom improvements for
both constipation and incontinence, although the improvement
lasted at least a year in patients with excellent responses. This is
rather a disappointing news for patients with constipation and in-
continence waiting for hopeful results of novel treatment.
However, it is too early to be disappointed.
When we read an article regarding the results of treatment in
specific patients group, several factors such as enrolled patients
group (strict diagnostic criteria), treatment method, and evalua-
tion of treatment efficacy should be carefully considered. I sug-
gest to meticulously analyze these factors in this article before
considering biofeedback treatment is as not so effective for con-
stipation and incontinence.
Biofeedback Therapy in Constipation and Incontinence
Vol. 16, No. 2 April, 2010 (110-112)
Firstly, not every enrolled patient might have been exactly
suitable for biofeedback therapy. In randomized controlled trial,
this therapy is effective in 70 to 86% of patients with dyssynergic
defecation.5-7 The diagnostic criteria for dyssynergic defecation is
well described in a recent review,8 which includes dyssynergic
anorectal manometric findings reflecting abnormal relexation
pattern or inadequate propulsive force plus abnormal findings
from balloon expulsion test, defecography, or colon transit time.8
It is proven in RCT that biofeedback benefits only patients with
outlet dysfunction, and no patients with isolated slow transit
constipation.9 In this article, as the authors mentioned in the dis-
cussion, the diagnostic criteria for constipation were not defined,
which could have led to the low response rate of biofeedback
among the enrolled constipated patients since patients with slow
transit constipation might have been included. It is under-
standable to try biofeedback therapy in medically intractable
constipation. However, analyzing the response rate of the therapy
according to the pathogenesis of the diseases would be beneficial.
Our group also tried to evaluate the variables to predict biofeed-
back responsiveness and found the defecation index and pelvic
floor dyssynergia to be the factors influencing the responses by
multivariate analysis.10 However, there is no consensus for mark-
ers in predicting the biofeedback response. In the future, we
should set up protocols to select the suitable patients for biofeed-
back therapy using adequate biomarkers.
Secondly, the method and protocol of biofeedback therapy
should be reviewed. The effectiveness of biofeedback training de-
pends in part on the skills of the biofeedback therapist and the se-
lection of particular techniques used for the training.2 In a recent
RCT, the patients were treated by a physician who highly experi-
enced in biofeedback training.11 The description of the biofeed-
back protocol was adequate in this article although there is a pos-
sibility that better protocol and method to induce more fair
response. In addition, this protocol lacked the sessions for sensory
retraining or strengthening of propulsive force for indicated
Thirdly, the evaluation criteria for the response rate are
important. The subjective reporting system including 4 catego-
ries used by authors are reasonable and widely used. However,
the evaluation of efficacy including objective and subjective in-
formations will add to the knowledge on the effectiveness of this
They reported intriguing observation of a higher sensory vol-
ume in nonresponsive than in responsive group. As the authors
have discussed, there might be a possibility that rectal hypo-
sensitivity is one of the parameters to predict poor response of bi-
ofeedback therapy.12 Our group suggested electrical stimulation
to be helpful for patients with rectal hyposensitivity, especially
among those who were unresponsive to biofeedback therapy.13,14
Further study is warranted to evaluate the importance of this nov-
el mechanism in constipation.
In summary, the article by Lee et al. provided valuable in-
formation about biofeedback therapy in Korean patients with
constipation and incontinence. However, the overall response
rate might have been underestimated due to patient’s selection
and/or short treatment period. The promising finding is the
long-term maintenance of improvement in the responsive
patients. They also suggested rectal hyposensitivity as a possible
biomarker for predicting biofeedback responsiveness which is a
valuable and plausible hypothesis. Further study is warranted to
evaluate the effectiveness of biofeedback therapy and to develop
biomarkers to predict the response of this therapy in Asian pa-
tients with constipation and incontinence.
1. Lembo A, Camilleri M. Chronic constipation. N Engl J Med
2. Enck P, Van der Voort IR, Klosterhalfen S. Biofeedback therapy in
fecal incontinence and constipation. Neurogastroenterol Motil
3. Chiarioni G, Whitehead WE. The role of biofeedback in the treat-
ment of gastrointestinal disorders. Nat Clin Pract Gastroenterol
4. Glia A, Gylin M, Gullberg K, Lindberg G. Biofeedback retraining
in patients with functional constipation and paradoxical puborectalis
contraction: comparison of anal manometry and sphincter electro-
myography for feedback. Dis Colon Rectum 1997;40:889-895.
5. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of bi-
ofeedback, sham feedback, and standard therapy for dyssynergic
defecation. Clin Gastroenterol Hepatol 2007;5:331-338.
6. Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead
WE. Randomized, controlled trial shows biofeedback to be superior
to alternative treatments for patients with pelvic floor dyssy-
nergia-type constipation. Dis Colon Rectum 2007;50:428-441.
7. Chiarioni G, Whitehead WE, Bassotti G. Randomized controlled
trial of biofeedback. Clin Gastroenterol Hepatol 2007;5:1119.
8. Rao SS. Dyssynergic defecation and biofeedback therapy. Gastroen-
terol Clin North Am 2008;37:569-586,viii.
9. Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only
patients with outlet dysfunction, not patients with isolated slow transit
constipation. Gastroenterology 2005;129:86-97.
10. Park DH, Myung SJ, Yoon IJ, et al. Clinical factors associated with
response to biofeedback therapy for patients with chronic
constipation. Korean J Gastroenterol 2003;42:289-296.
11. Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G.
Journal of Neurogastroenterology and Motility
Biofeedback is superior to laxatives for normal transit constipation
due to pelvic floor dyssynergia. Gastroenterology 2006;130:657-664.
12. Gladman MA, Lunniss PJ, Scott SM, Swash M. Rectal
hyposensitivity. Am J Gastroenterol 2006;101:1140-1151.
13. Chang HS, Myung SJ, Yang SK, et al. Effect of electrical stim-
ulation in constipated patients with impaired rectal sensation. Int J
Colorectal Dis 2003;18:433-438.
14. Chang HS, Myung SJ, Yang SK, et al. Functional constipation with
impaired rectal sensation improved by electrical stimulation therapy:
report of a case. Dis Colon Rectum 2004;47:933-936.