1. Manometric Biofeedback Effectively Performed on
Patients Suffering from Dyssynergic Constipation
Barbara Deering, PT, CLT-LANA, CAPP-PELVIC
Chart 1. Patient A. Session 1, 6/28/17. Expel Full Exercise. Rectal Pressure
19 mmHg , Sphincter Pressure 48 mmHg. Anorectal Gradient -29 mmHg
OBJECTIVE: Functional constipation is a common bowel disorder that can lead to decreased activity and reduction in health-related quality of life. Typically, this disorder is treated with medical management utilizing prescription laxatives, additional fiber supplements, or a combination of both. These interventions can often be ineffective and fail to address the underlying pathophysiology of the condition, leaving patients suffering and frustrated. Physical Therapists specializing in pelvic floor retraining possess the knowledge and skills to diagnose and manage a wide variety of musculoskeletal and motor coordination impairments that may contribute to functional constipation. This study was designed to determine if manometric biofeedback or EMG biofeedback would be more beneficial to the patients with functional constipation (dyssynergia).
RESULTS (cont) : Though the patient was given medication to assist in the stool form and consistency, she had continued to demonstrate difficulty in defecation. It was when she participated in the manometric biofeedback that she truly saw success over only 5 visits. Upon completion of the therapy the patient reported to have a daily bowel movement and no longer had any abdominal pain.
The Chart 1 and Chart 2 represent the anorectal gradient of this patient. At the beginning of the treatment (Session 1), at her best trial the patient exhibited paradoxical coordination between rectal walls (labeled as “rectum” on both charts) and sphincter muscles (labeled as “anal” on both charts), squeezing sphincters above her resting pressures at 48 mmHg and emitting only 19 mmHg from the rectal walls. The anorectal gradient was negative 29 mmHg. Per Chart 2, during the final session (Session 5), while bearing down at her best trial the patient was able to increase her rectal wall pressures to 78mmHg (75% increase from Session 1) and keeping her sphincters relaxed under resting pressures, at 17 mmHg (65% decline from Session 1), yielding a positive gradient of 61 mmHg.
METHODS: The mcompass® manometric biofeedback (Medspira, Minneapolis, MN) is a portable and wireless device that employs disposable, air-charged catheters. The biofeedback software intuitively guides therapists and patients throughout the treatment (patients are guided with visual cues on a separate monitor). Patients were chosen based on referral from a physician with diagnosis of dyssynergia. Barbara Deering, the pelvic floor specialist from Florida Hospital DeLand, performed all treatment sessions in this study. The participating patients underwent 4 to 5 treatment sessions conducted on weekly or bi-weekly basis. Each session took between minutes to complete. For the EXPEL FULL exercise the patients were seated on a commode chair to better simulate real conditions during evacuation. The rectal balloon of the catheter was inflated with 60 ml of air to simulate full bowel. With the 1st treatment session the focus was put on establishing the ideal body position, the best foot elevation, and the proper abdominal breathing technique was rehearsed. During all subsequent treatment sessions the patients worked on improving their breathing technique and incorporating Transverse abdominal contraction into their bowel movement routine. Coordination of the anorectal muscles was observed during the treatment by both, therapist and patients. In between the treatment sessions patients were instructed to rehearse the proper body posture and abdominal breathing technique, including Transverse Abdominal Contraction, every time they felt the slightest sensation to have a bowel movement.
CONCLUSION: Constipation is a multifactorial disease with many symptoms requiring, other interventions and a multidimensional approach. Dyssynergic defecation is a complex condition that responds well to biofeedback as noted in numerous randomized controlled trials. The purpose of this study was to determine the difference between the use of EMG biofeedback and the mcompass® manometric biofeedback. The patients who participated in the study have had EMG biofeedback, which only shows muscle activity of the entire pelvic floor area. With manometric biofeedback by mcompass®, both the STRENGTH and EXPEL FULL exercises are able to separate the anal sphincter and the rectal wall pressures to allow for true visual feedback for both, the therapist and patients. During the therapy the patients were placed in a seated “toileting” position on a commode chair at varied heights and angles to assess their optimum placement using these visual cues. The patients then could utilize various methods from Transverse Abdominal Contractions, Diaphragmatic Breathing Techniques, massage, and visceral techniques to assist in the completion of defecation.
The patients did demonstrate an improved understanding of proper toileting positioning and could visualize the importance of proper toilet height and angle to achieve the optimal anorectal position for defecation. Patients could visualize the improvement of their anal sphincter relaxation and the increase of their rectal wall pressure with noted improved toileting success. These visual cues were instrumental in teaching patients to properly bear down while trying to have a bowel movement. The patients’ satisfaction was higher with the use of manometric biofeedback by mcompass® as they could put the trialed techniques into practice and were more successful to have bowel movement at home. Although this was a small study with only 4 patients, the use of manometric biofeedback with the patients suffering with dyssynergic defecation made a significant change in their success rate with improved ability to manage bowel movement. It further demonstrated the use of interventions that can be effective in a short period of time and make significant improvements in a patient’s quality of life.
Chart 2. Patient A. Session 5, 8/23/17. Expel Full Exercise. Rectal Pressure
78 mmHg , Sphincter Pressure 17mmHg. Anorectal Gradient +61 mmHg
RESULTS : A convenient sample of 4 patients exhibiting dyssynergic evacuation disorder participated in the study. Upon completion of the treatment, anorectal gradients from the first and last sessions were compared to quantify the improvement patients made in their ability to have a bowel movement. Additionally, patients’ feedback on the treatment outcomes were solicited and documented. Result, 3 out of 4 patients responded positively to the EXPEL FULL exercise. The patient who showed the most success with the therapy also had multiple surgical interventions for which she was unable to tolerate any surgical closures and was left open to heal (due to allergies), causing significant scarring. This patient initiated her treatment with defecation weekly and significant abdominal pain. Her scarring, however, responded well to multipoint stimulation, Myofascial Decompression, manual techniques, massaging the large colon to assist with movement of the stool through it.