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An alternative biofeedback-based behavior modification treatment for a case of chronic constipation
Q
(IlKli-7Ylh/Y? $5.IMl + ,,.,“I I’JYZ Pcrgtmon Prcw L.fd
AN ALTERNATIVE BIOFEEDBACK-BASED BEHAVIOR MODIFICATION TREATMENT FOR A CASE OF CHRONIC CONSTIPATION JANICE Virginia
Consortium
for Professional
M. SINGLES
Psychology,
PETER
Medical Center
University
J. COX and RAVINDER University
of Virginia
J. MIKULKA
Old Dominion
DANIEL
University
of Virginia
K. MITTAL
Medical Center
Summary - A 31-year old female with chronic constipation was referred for treatment of a paradoxical contraction of the external anal sphincter (EAS) muscle during straining to defecate. The patient was dependent on laxative use and the digital removal of feces. The present program emphasized biofeedback training of the EAS utilizing the inexpensive, noninvasive procedure of disposable surface electrodes placed on the anal verge. Outcome of treatment resulted in an 89% decrease in laxatives used. complete termination of the digital removal of feces, and a notable decrease in EAS tension. The patient was able to maintain these gains at an 8 month follow-up.
Although biofeedback has been considered the “treatment of choice” for fecal incontinence (Whitehead and Schuster, 1985), there has been significantly less research conducted on this technique with another defecation disorder, chronic constipation. In fact, chronic constipation has historically received little treatment attention beyond laxative and dietary prescriptions. One medical text describes it as “perhaps the commonest(sic) disease known to man” (Jones, Brunt and Mowat, 1985) with one survey suggesting that diagnosable constipation may occur in healthy populations at a rate of 2.9% in the young, 8.2% in the middle-aged, and 20% in the elderly (Thompson & Heaton, 1980). Recently, several articles have described the use of manometric biofeedback methods to treat successfully some types of chronic constipation (Loening-Baucke. 1990; McCubbin, Surwit and Mansbach, 1987; van Baal, Leguit
and Brummelkamp, 1984; Weber et al., 1987). This manometric device, created by Engel, Nikoomanesh and Shuster (1974) for the treatment of fecal incontinence, is a three-balloon rectal tube that provides simultaneous measurement of activity of both internal and external anal sphincters, as well as distension of the rectum to simulate a fecal mass. Although “very satisfactory clinical outcomes” have been produced with this technique, Whitehead and Schuster (1985) note three problems with manometric biofeedback. First, it is expensive and not generally available. Second, the visual feedback display is poor due to the large amount of distracting and irrelevant information that is unnecessary for treatment. Third, the activity changes recorded from the balloons are not specific to the external anal sphincter (EAS) muscle but may also include contraction of adjacent muscles or other body movements. In addition to these
Requests for reprints should be addressed to Janice M Singles, Community .,_.,. .. ^ Psychology. 1500 North Ritter Avenue. Indianapolis, IN WLIY, U.S.A
231
Hospital.
Department
of Medical
232
JANICE
M. SINGLES
disadvantages, the procedure is physically and psychologically intrusive, requiring the anal insertion of the g-inch long apparatus. It has been suggested by others that invasive manometric devices may not be necessary for the successful treatment of disorders involving the EAS muscle. MacLeod (1987) used an anal plug, which primarily monitors the EAS muscle, to treat a large group of incontinent patients. An even less invasive, less expensive, and simpler method of biofeedback was used by Sims, Remler and Cox (1987). The authors used EMG surface electrodes with placement on the anal verge to treat successfully cases of encopresis and urinary stress incontinence. The present treatment was designed as an alternative to complicated, expensive and invasive manometric techniques for the treatment of chronic constipation due to EAS dysfunction. This treatment program is described in the following sections and was used to treat a young woman with chronic constipation due to EAS dysfunction.
Methods The patient was a 31-year-old married white female homemaker. She was referred for treatment by her gastroenterologist after an anorectal motility study found that she experienced excessive tension in her EAS muscle while straining to defecate. She reported a 7-year history of chronic constipation symptoms that began following the birth of a child. Since then she had relied on the daily use of a powdered laxative (Citrucel) and the digital removal of feces in order to pass a bowel movement. Recent rectal bleeding, that was attributed to hemorrhoids, precipitated her seeking medical attention. At the beginning of treatment, the patient was having an average of 11 bowel movements per week while utilizing laxatives twice each day (a total of 8 teaspoons a day of Citrucel) with digital removal occurring once each day. She also complained of abdominal pain, which was usually relieved by passing a
et al
stool. Only a mild impairment in rectal sensation was noted by her gastroenterologist during her anorectal motility study. The patient presented no other prior or current physical or psychological problems. No information regarding gastrointestinal problems in her family of origin was available. Materials The biofeedback equipment utilized was the Autogen 1700. One channel of EMG was used for collecting data at the beginning and end of each treatment assessment period, as well as in conducting the weekly biofeedback treatments. Anal sphincter tension was measured in microvolts. This system also provided a hard copy print-out of the assessment period averages. Disposable pediatric EKG electrodes (Hewlett Packard HP 40426A) and surgical gloves were utilized to insure optimal health and safety of the patient and therapist (primary author). The biofeedback hook-up procedure was completed while the patient was prone on an examining table. All baseline EMG assessments were conducted with the patient resting on the table. A portable toilet was utilized to assist in the simulation of relaxation in the home environment. Sound intensity was used as the biofeedback signal, and decreasing muscle tension lowered the sound level. Procedures Prior to the beginning of treatment, the patient completed daily diary sheets for one month. This diary provided information concerning daily bowel movements, their frequency, their time of day, estimated size and method used to induce a bowel movement, i.e., laxative, enema, digital removal, etc. This daily recording of constipation symptoms was continued throughout the course of treatment, as well as during the one month follow-up period. For the 8 month follow-up, the patient completed a week of daily diary recordings.
Alternative
Biofeedback-based
The standard hook-up procedure included attaching the electrodes bilaterally to the anal opening, with the ground electrode placed on the patient’s coccyx. The EMG measurements of the EAS muscle tension were taken at the beginning and end of each treatment session. The procedure for these pre- and posttreatment assessment periods was the same: an initial resting baseline of the EAS muscle was first collected over a 60-second period and following this, the patient was asked to simulate straining to defecate for a lo-second period. These EMG recordings served as a baseline to compare any changes that occurred in muscle tension either across treatment sessions or within (pre-post) each session. Additionally, the patient was instructed in three alternating lo-second trials of relaxing and then tensing the EAS. These EMG scores were then averaged separately for both relaxing and tensing of the EAS. During the pre-post measurements no feedback was provided to the patient. The following is an outline of the treatment activities and homework of each session. Session one provided the patient with information about the anatomy and physiology of bowel function, provided a rationale for treatment, and initiated auditory feedback of the EMG signal with instruction to “turn off the sound” and relax the muscle. The patient was also instructed in progressive muscle relaxation. Homework included daily progressive muscle relaxation practice using an audiotape, sphincter exercises similar to those done during biofeedback, a consistent 15-minute toilet time each day, and the use of a Fleets enema if no bowel movement occurred for a 2-day period. Session two focused on training the patient to relax the EAS muscle during simulated straining to defecate, and introduced the patient to a constipation-specific relaxation tape to be used while on the toilet each day. Homework remained the same, except that the constipation-specific tape replaced the progressive muscle relaxation tape. Session three included continued training in
Behavior
Modification
233
Treatment
EAS relaxation during straining to defecate. A portable toilet was used during the session to simulate a natural environment. Homework remained the same as session two, except the patient was now provided with a choice of what on-the-toilet relaxation technique she wished to use, i.e., audio tapes, sphincter exercises, general relaxation. In addition, the patient was instructed to decrease laxative use by 50%. Session four reinforced the gains made in treatment and continued practice of EAS muscle biofeedback during straining. Homework was identical to session three except the patient was asked to terminate laxative use. Session five was the same as session four and included instructions for follow-up.
Results Prior to the initiation of treatment, the patient was utilizing digital removal of feces to relieve constipation an average of 11 times per week. After the first week of treatment the use of this technique was reduced by 37%. By the second week of treatment, digital removal was completely abandoned and remained so throughout subsequent treatment and at 1 and 8 months follow-up (see Table 1). A reduction in the use of laxatives began after session three
Table
1.
Laxative use per week, bowel movements per week, and use of digital removal per week for sessions one to five and follow-ups
Laxative use CitruceUTBSP per week Session One Session Two Session Three Session Four Session Five One month* Eight month* *Denotes
Follow-up.
56 56 56 28 6 6 6
Bowel movements per week I1 9 9 15 14 15 14
Digital removal per week 11 7 0 0 0 0 0
234
JANICE
M. SINGLES
and continued to decrease over the final sessions of treatment. The patient was able to reduce the total amount of laxative (from baseline) to 50% by the fourth session, and the total laxative usage was reduced to less than 11% of baseline by session five. During baseline the frequency of laxative use was 14 times per week and this decreased to only 3 times per week by the end of treatment. More importantly, the actual amount of laxative (Citrucel) used by the patient decreased from a dosage of 56 teaspoons per week at baseline to 6 tcaspoons per week at treatment termination. The patient utilized only one enema during the entire treatment. This pattern of symptom reduction over sessions occurred while total weekly bowel movements gradually increased and stabilized over the last four measurement periods. In addition, the patient had totally eliminated abdominal pain by the end of treatment. Data was collected for EMG levels during simulation of straining to defecate at the beginning and end of each treatment session period and over all sessions. Examination of &hin session straining to defecate showed a decrease in EMG tension that was substantial, while beginning session EMG levels showed a similar reduction over sessions (see Table 2). At one month follow-up by mail the patient maintained all therapeutic gains. She had approximately 15 bowel movement per week, which represented a 27% increase from her pre-treatment baseline. She maintained her Table
2.
Straining Pre-session EMG Session Session Session Session Session
One Two Three Four Five
3.6 2.7 2.x 2.5 2.4
Post-session EMG 1.4 2.0 1.6 1.7 1.9
ct al
minimal laxative use, had not used digital removal and noted no abdominal pain. At the &month follow-up, the patient continued to maintain all therapeutic gains. A follow-up manometric examination by her gastroenterologist at 3 months post-treatment supported the observed treatment gains. This examination showed that the patient no longer evidenced the paradoxical contractions of the EAS muscle during straining to defecate.
Discussion Although there are many possible causes for constipation, the failure of adults to relax the EAS muscle while attempting defecation has been suggested by several authors (Preston and Lennard-Jones, 1981; Read et al., 1986). In addition, Keren et al. (198X) found this EAS dysfunction in a majority of constipated children. The patient in this case study demonstrated this paradoxical contraction. A comprehensive behavior modification program was developed which emphasized training to relax the EAS muscle while straining to defecate. The marked and rapid improvement in the patient’s symptoms during treatment suggests that a brief behavior modification program, with EMG biofeedback-assisted training utilizing surface electrodes, can successfully treat patients with chronic constipation due to EAS dysfunction. This brief treatment offers an effective addition to the traditional use of lax,ative and dietary prescriptions alone. Further, it provides a more simple alternative to the more expensive, complicated and invasive manometric biofeedback training and, may make this treatment more therefore, accessible and acceptable to potential patients. While it is unclear how other chronically constipated individuals would respond. this patient was unwilling to totally eliminate laxative use. She was able, however, to dramatically decrease her overall intake, resulting in an 89% reduction in total laxative use from baseline. Her continued use of small, possibly
Alternative
Biofeedback-based
non-therapeutic, doses appeared to be based on a fear of reoccurrence of a past episode of painful impaction. EMG assessment data suggests that the patient was able rapidly to learn to decrease EAS muscle tension during straining. This is particularly apparent during within session procedures but a similar substantial reduction occurred between the first and second treatment session. This EAS tension reduction was supported by information from the follow-up anorectal motility study which showed that the patient no longer initiated a paradoxical contraction during straining to defecate. This is important since she was referred to treatment after an initial examination showed that she had dyscoordinated EAS functioning. Since normal individuals experience EAS relaxation during straining, training this patient in EAS control was a critical goal of treatment. The results from this case study are encouraging, but further research will be needed to confirm this preliminary finding. Further, changes in EAS muscle tension during treatment were accompanied by decreases in the use of laxatives, the termination of digital removal of fecal matter, and the elimination of abdominal pain. Similar effects were noted by Keren et al. (1988), using manometric feedback to treat constipated children with EAS dysfunction. This suggests that when patients with EAS dysfunction retrain their muscle to relax during straining, ongoing symptomatology is reduced. However, it is also possible that factors other than specific EAS muscle training may influence positive outcome. In the present case, it is not possible to differentiate the impact of the other components of treatment (e.g., relaxation training, and practice at tensing and relaxing the anal sphincter muscle) from the role of the specific EAS muscle retraining. Since this treatment nrogram was comprehensive, future research
Behavior
Modification
Treatment
235
will be needed to focus on the importance of specific EAS muscle retraining in reducing chronic constipation.
References Engel, B. T., Nikoomanesh, P.. & Schuster, M. M. (1974). Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. New England Journal of Medicine, 290, 64&649. Jones. P. F.. Brunt. P. W., & Mowat. N. A. (Eds j (1985). Gastroenterolog)~. Chicago: Year Book Medical Publishers. Keren, S., Wagner. Y.. Heldenberg, D.. & Golan, M. (1988). Studies of manometric abnormalities of the rectoanal region during defecation in constipated and soiling children: modification through biofeedback ther;;;: Americarl Journal of Gastroenterology. 83. 827Loening-Baucke, V. (1990). Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. Journal of Pediatrics, 116, 214-222. MacLeod. J. H. (1987). Management of anal incontinence by biofeedback. Gastroenterology. 198, 291-294. McCubbin, J. A., Surwit. R. S.. & Mansbach. C. M. (1987). Sensory discrimination training in the treatment of a case of chronic constipation. Behavior Therapy, 18. 273-278. Preston. D. M.. & Lennard-Jones, J. E. (1981). Is there a pelvic floor disorder in slow transit constipation? Gut, 22, A488. Read, N. W.. Timms, J. M.. Barfield, C. J.. Donnelly, T. C.. & Bannister, J. J. (1986). Impairment of defecation in young women with severe constipation. Gastroenterology, 90. 53-60. Sims, C. G.. Remler, H.. & Cox. D. J. (1987). Biofeedback and behavioral treatment of elimination disorders. Clinical Biofeedback and Health. IO. 28-55. Thompson, W. G.. & Heaton, K. W. (1980). Functional bowel disorders in apparently healthy people. Gastroenterology, 79, 283-i&. _ van Baal. J. G.. Leruit. P., & Brummelkamp. W. P (1984). Relaxation-biofeedback conditioning as trea;: ment of a disturbed defecation reflex. Diseases of the Colon and Rectum. 27, 187-189. Weber. J., Ducrotte, P. H., Touchais. J. Y., Roussignol, C., & Denis, P. H. (1987). Biofeedback training for constipation in adults and children. Diseases of the ._ Colon’ and Rectum, 30. 844-846. Whitehead. W. E.. & Schuster, M. M. (1985). Gastmintestinal disorders: behavioral and physiolo&cal basis for treatment. New York: Academic Press, Inc.
(IlKli-7Ylh/Y? $5.IMl + ,,.,“I I’JYZ Pcrgtmon Prcw L.fd
AN ALTERNATIVE BIOFEEDBACK-BASED BEHAVIOR MODIFICATION TREATMENT FOR A CASE OF CHRONIC CONSTIPATION JANICE Virginia
Consortium
for Professional
M. SINGLES
Psychology,
PETER
Medical Center
University
J. COX and RAVINDER University
of Virginia
J. MIKULKA
Old Dominion
DANIEL
University
of Virginia
K. MITTAL
Medical Center
Summary - A 31-year old female with chronic constipation was referred for treatment of a paradoxical contraction of the external anal sphincter (EAS) muscle during straining to defecate. The patient was dependent on laxative use and the digital removal of feces. The present program emphasized biofeedback training of the EAS utilizing the inexpensive, noninvasive procedure of disposable surface electrodes placed on the anal verge. Outcome of treatment resulted in an 89% decrease in laxatives used. complete termination of the digital removal of feces, and a notable decrease in EAS tension. The patient was able to maintain these gains at an 8 month follow-up.
Although biofeedback has been considered the “treatment of choice” for fecal incontinence (Whitehead and Schuster, 1985), there has been significantly less research conducted on this technique with another defecation disorder, chronic constipation. In fact, chronic constipation has historically received little treatment attention beyond laxative and dietary prescriptions. One medical text describes it as “perhaps the commonest(sic) disease known to man” (Jones, Brunt and Mowat, 1985) with one survey suggesting that diagnosable constipation may occur in healthy populations at a rate of 2.9% in the young, 8.2% in the middle-aged, and 20% in the elderly (Thompson & Heaton, 1980). Recently, several articles have described the use of manometric biofeedback methods to treat successfully some types of chronic constipation (Loening-Baucke. 1990; McCubbin, Surwit and Mansbach, 1987; van Baal, Leguit
and Brummelkamp, 1984; Weber et al., 1987). This manometric device, created by Engel, Nikoomanesh and Shuster (1974) for the treatment of fecal incontinence, is a three-balloon rectal tube that provides simultaneous measurement of activity of both internal and external anal sphincters, as well as distension of the rectum to simulate a fecal mass. Although “very satisfactory clinical outcomes” have been produced with this technique, Whitehead and Schuster (1985) note three problems with manometric biofeedback. First, it is expensive and not generally available. Second, the visual feedback display is poor due to the large amount of distracting and irrelevant information that is unnecessary for treatment. Third, the activity changes recorded from the balloons are not specific to the external anal sphincter (EAS) muscle but may also include contraction of adjacent muscles or other body movements. In addition to these
Requests for reprints should be addressed to Janice M Singles, Community .,_.,. .. ^ Psychology. 1500 North Ritter Avenue. Indianapolis, IN WLIY, U.S.A
231
Hospital.
Department
of Medical
232
JANICE
M. SINGLES
disadvantages, the procedure is physically and psychologically intrusive, requiring the anal insertion of the g-inch long apparatus. It has been suggested by others that invasive manometric devices may not be necessary for the successful treatment of disorders involving the EAS muscle. MacLeod (1987) used an anal plug, which primarily monitors the EAS muscle, to treat a large group of incontinent patients. An even less invasive, less expensive, and simpler method of biofeedback was used by Sims, Remler and Cox (1987). The authors used EMG surface electrodes with placement on the anal verge to treat successfully cases of encopresis and urinary stress incontinence. The present treatment was designed as an alternative to complicated, expensive and invasive manometric techniques for the treatment of chronic constipation due to EAS dysfunction. This treatment program is described in the following sections and was used to treat a young woman with chronic constipation due to EAS dysfunction.
Methods The patient was a 31-year-old married white female homemaker. She was referred for treatment by her gastroenterologist after an anorectal motility study found that she experienced excessive tension in her EAS muscle while straining to defecate. She reported a 7-year history of chronic constipation symptoms that began following the birth of a child. Since then she had relied on the daily use of a powdered laxative (Citrucel) and the digital removal of feces in order to pass a bowel movement. Recent rectal bleeding, that was attributed to hemorrhoids, precipitated her seeking medical attention. At the beginning of treatment, the patient was having an average of 11 bowel movements per week while utilizing laxatives twice each day (a total of 8 teaspoons a day of Citrucel) with digital removal occurring once each day. She also complained of abdominal pain, which was usually relieved by passing a
et al
stool. Only a mild impairment in rectal sensation was noted by her gastroenterologist during her anorectal motility study. The patient presented no other prior or current physical or psychological problems. No information regarding gastrointestinal problems in her family of origin was available. Materials The biofeedback equipment utilized was the Autogen 1700. One channel of EMG was used for collecting data at the beginning and end of each treatment assessment period, as well as in conducting the weekly biofeedback treatments. Anal sphincter tension was measured in microvolts. This system also provided a hard copy print-out of the assessment period averages. Disposable pediatric EKG electrodes (Hewlett Packard HP 40426A) and surgical gloves were utilized to insure optimal health and safety of the patient and therapist (primary author). The biofeedback hook-up procedure was completed while the patient was prone on an examining table. All baseline EMG assessments were conducted with the patient resting on the table. A portable toilet was utilized to assist in the simulation of relaxation in the home environment. Sound intensity was used as the biofeedback signal, and decreasing muscle tension lowered the sound level. Procedures Prior to the beginning of treatment, the patient completed daily diary sheets for one month. This diary provided information concerning daily bowel movements, their frequency, their time of day, estimated size and method used to induce a bowel movement, i.e., laxative, enema, digital removal, etc. This daily recording of constipation symptoms was continued throughout the course of treatment, as well as during the one month follow-up period. For the 8 month follow-up, the patient completed a week of daily diary recordings.
Alternative
Biofeedback-based
The standard hook-up procedure included attaching the electrodes bilaterally to the anal opening, with the ground electrode placed on the patient’s coccyx. The EMG measurements of the EAS muscle tension were taken at the beginning and end of each treatment session. The procedure for these pre- and posttreatment assessment periods was the same: an initial resting baseline of the EAS muscle was first collected over a 60-second period and following this, the patient was asked to simulate straining to defecate for a lo-second period. These EMG recordings served as a baseline to compare any changes that occurred in muscle tension either across treatment sessions or within (pre-post) each session. Additionally, the patient was instructed in three alternating lo-second trials of relaxing and then tensing the EAS. These EMG scores were then averaged separately for both relaxing and tensing of the EAS. During the pre-post measurements no feedback was provided to the patient. The following is an outline of the treatment activities and homework of each session. Session one provided the patient with information about the anatomy and physiology of bowel function, provided a rationale for treatment, and initiated auditory feedback of the EMG signal with instruction to “turn off the sound” and relax the muscle. The patient was also instructed in progressive muscle relaxation. Homework included daily progressive muscle relaxation practice using an audiotape, sphincter exercises similar to those done during biofeedback, a consistent 15-minute toilet time each day, and the use of a Fleets enema if no bowel movement occurred for a 2-day period. Session two focused on training the patient to relax the EAS muscle during simulated straining to defecate, and introduced the patient to a constipation-specific relaxation tape to be used while on the toilet each day. Homework remained the same, except that the constipation-specific tape replaced the progressive muscle relaxation tape. Session three included continued training in
Behavior
Modification
233
Treatment
EAS relaxation during straining to defecate. A portable toilet was used during the session to simulate a natural environment. Homework remained the same as session two, except the patient was now provided with a choice of what on-the-toilet relaxation technique she wished to use, i.e., audio tapes, sphincter exercises, general relaxation. In addition, the patient was instructed to decrease laxative use by 50%. Session four reinforced the gains made in treatment and continued practice of EAS muscle biofeedback during straining. Homework was identical to session three except the patient was asked to terminate laxative use. Session five was the same as session four and included instructions for follow-up.
Results Prior to the initiation of treatment, the patient was utilizing digital removal of feces to relieve constipation an average of 11 times per week. After the first week of treatment the use of this technique was reduced by 37%. By the second week of treatment, digital removal was completely abandoned and remained so throughout subsequent treatment and at 1 and 8 months follow-up (see Table 1). A reduction in the use of laxatives began after session three
Table
1.
Laxative use per week, bowel movements per week, and use of digital removal per week for sessions one to five and follow-ups
Laxative use CitruceUTBSP per week Session One Session Two Session Three Session Four Session Five One month* Eight month* *Denotes
Follow-up.
56 56 56 28 6 6 6
Bowel movements per week I1 9 9 15 14 15 14
Digital removal per week 11 7 0 0 0 0 0
234
JANICE
M. SINGLES
and continued to decrease over the final sessions of treatment. The patient was able to reduce the total amount of laxative (from baseline) to 50% by the fourth session, and the total laxative usage was reduced to less than 11% of baseline by session five. During baseline the frequency of laxative use was 14 times per week and this decreased to only 3 times per week by the end of treatment. More importantly, the actual amount of laxative (Citrucel) used by the patient decreased from a dosage of 56 teaspoons per week at baseline to 6 tcaspoons per week at treatment termination. The patient utilized only one enema during the entire treatment. This pattern of symptom reduction over sessions occurred while total weekly bowel movements gradually increased and stabilized over the last four measurement periods. In addition, the patient had totally eliminated abdominal pain by the end of treatment. Data was collected for EMG levels during simulation of straining to defecate at the beginning and end of each treatment session period and over all sessions. Examination of &hin session straining to defecate showed a decrease in EMG tension that was substantial, while beginning session EMG levels showed a similar reduction over sessions (see Table 2). At one month follow-up by mail the patient maintained all therapeutic gains. She had approximately 15 bowel movement per week, which represented a 27% increase from her pre-treatment baseline. She maintained her Table
2.
Straining Pre-session EMG Session Session Session Session Session
One Two Three Four Five
3.6 2.7 2.x 2.5 2.4
Post-session EMG 1.4 2.0 1.6 1.7 1.9
ct al
minimal laxative use, had not used digital removal and noted no abdominal pain. At the &month follow-up, the patient continued to maintain all therapeutic gains. A follow-up manometric examination by her gastroenterologist at 3 months post-treatment supported the observed treatment gains. This examination showed that the patient no longer evidenced the paradoxical contractions of the EAS muscle during straining to defecate.
Discussion Although there are many possible causes for constipation, the failure of adults to relax the EAS muscle while attempting defecation has been suggested by several authors (Preston and Lennard-Jones, 1981; Read et al., 1986). In addition, Keren et al. (198X) found this EAS dysfunction in a majority of constipated children. The patient in this case study demonstrated this paradoxical contraction. A comprehensive behavior modification program was developed which emphasized training to relax the EAS muscle while straining to defecate. The marked and rapid improvement in the patient’s symptoms during treatment suggests that a brief behavior modification program, with EMG biofeedback-assisted training utilizing surface electrodes, can successfully treat patients with chronic constipation due to EAS dysfunction. This brief treatment offers an effective addition to the traditional use of lax,ative and dietary prescriptions alone. Further, it provides a more simple alternative to the more expensive, complicated and invasive manometric biofeedback training and, may make this treatment more therefore, accessible and acceptable to potential patients. While it is unclear how other chronically constipated individuals would respond. this patient was unwilling to totally eliminate laxative use. She was able, however, to dramatically decrease her overall intake, resulting in an 89% reduction in total laxative use from baseline. Her continued use of small, possibly
Alternative
Biofeedback-based
non-therapeutic, doses appeared to be based on a fear of reoccurrence of a past episode of painful impaction. EMG assessment data suggests that the patient was able rapidly to learn to decrease EAS muscle tension during straining. This is particularly apparent during within session procedures but a similar substantial reduction occurred between the first and second treatment session. This EAS tension reduction was supported by information from the follow-up anorectal motility study which showed that the patient no longer initiated a paradoxical contraction during straining to defecate. This is important since she was referred to treatment after an initial examination showed that she had dyscoordinated EAS functioning. Since normal individuals experience EAS relaxation during straining, training this patient in EAS control was a critical goal of treatment. The results from this case study are encouraging, but further research will be needed to confirm this preliminary finding. Further, changes in EAS muscle tension during treatment were accompanied by decreases in the use of laxatives, the termination of digital removal of fecal matter, and the elimination of abdominal pain. Similar effects were noted by Keren et al. (1988), using manometric feedback to treat constipated children with EAS dysfunction. This suggests that when patients with EAS dysfunction retrain their muscle to relax during straining, ongoing symptomatology is reduced. However, it is also possible that factors other than specific EAS muscle training may influence positive outcome. In the present case, it is not possible to differentiate the impact of the other components of treatment (e.g., relaxation training, and practice at tensing and relaxing the anal sphincter muscle) from the role of the specific EAS muscle retraining. Since this treatment nrogram was comprehensive, future research
Behavior
Modification
Treatment
235
will be needed to focus on the importance of specific EAS muscle retraining in reducing chronic constipation.
References Engel, B. T., Nikoomanesh, P.. & Schuster, M. M. (1974). Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. New England Journal of Medicine, 290, 64&649. Jones. P. F.. Brunt. P. W., & Mowat. N. A. (Eds j (1985). Gastroenterolog)~. Chicago: Year Book Medical Publishers. Keren, S., Wagner. Y.. Heldenberg, D.. & Golan, M. (1988). Studies of manometric abnormalities of the rectoanal region during defecation in constipated and soiling children: modification through biofeedback ther;;;: Americarl Journal of Gastroenterology. 83. 827Loening-Baucke, V. (1990). Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. Journal of Pediatrics, 116, 214-222. MacLeod. J. H. (1987). Management of anal incontinence by biofeedback. Gastroenterology. 198, 291-294. McCubbin, J. A., Surwit. R. S.. & Mansbach. C. M. (1987). Sensory discrimination training in the treatment of a case of chronic constipation. Behavior Therapy, 18. 273-278. Preston. D. M.. & Lennard-Jones, J. E. (1981). Is there a pelvic floor disorder in slow transit constipation? Gut, 22, A488. Read, N. W.. Timms, J. M.. Barfield, C. J.. Donnelly, T. C.. & Bannister, J. J. (1986). Impairment of defecation in young women with severe constipation. Gastroenterology, 90. 53-60. Sims, C. G.. Remler, H.. & Cox. D. J. (1987). Biofeedback and behavioral treatment of elimination disorders. Clinical Biofeedback and Health. IO. 28-55. Thompson, W. G.. & Heaton, K. W. (1980). Functional bowel disorders in apparently healthy people. Gastroenterology, 79, 283-i&. _ van Baal. J. G.. Leruit. P., & Brummelkamp. W. P (1984). Relaxation-biofeedback conditioning as trea;: ment of a disturbed defecation reflex. Diseases of the Colon and Rectum. 27, 187-189. Weber. J., Ducrotte, P. H., Touchais. J. Y., Roussignol, C., & Denis, P. H. (1987). Biofeedback training for constipation in adults and children. Diseases of the ._ Colon’ and Rectum, 30. 844-846. Whitehead. W. E.. & Schuster, M. M. (1985). Gastmintestinal disorders: behavioral and physiolo&cal basis for treatment. New York: Academic Press, Inc.