Biofeedback methodology: does it matter how we teach children how to relax the pelvic floor during voiding?

PURPOSE: Biofeedback is a noninvasive treatment that has been documented to be helpful for children with daytime wetting and/or urinary tract infection secondary to voiding dysfunction. We wish to determine the effectiveness of biofeedback in a large population of children presenting with voiding dysfunction, and evaluate differences between 2 different methods with regard to resolution of symptoms, improvement of objective measurements and patient satisfaction. MATERIALS AND METHODS: The charts of 102 consecutive patients treated with biofeedback were reviewed. Of the patients 21 were asked to void 4 to 8 times in 6 hours seated in front of a uroflow device while receiving coaching by a staff member (method 1), 56 were taught pelvic floor relaxation techniques in front of a computer monitor that displayed electromyogram readings for 45 to 90 minutes (method 2), and both methods were used in 25. Outcome variables were obtained through chart review and telephone contact, and included resolution of symptoms, elimination of urinary tract infection, character of voiding curve, post-void residual, decrease in relaxation score and parental satisfaction. RESULTS: Females comprised 79% of the population and median age at first treatment was 7.7 years (range 4.3 to 15.4 y). Daytime wetting was seen in 84% and recurrent urinary tract infection in 66% of patients. Among children with daytime wetting there was 100% success or improvement with method 1, 91% with method 2 and 80% with both methods (p not significant). Among those with urinary tract infection, 25% had subsequent infection with method 1, 25% with method 2 and 31% with both methods (p not significant). Normalization of the flow curve was seen in 94% with method 1, 67% with method 2 and 30% with both methods. Patients using both methods had a significantly greater post-void residual compared to patients using method 1 (0 versus 33%, p = 0.003). Relaxation scores decreased a median of 6.5% in with method 2 and 20% with both methods. After a median followup of 1.8 years 98% of parents expressed satisfaction with biofeedback with more than 80% indicating a high degree of satisfaction. CONCLUSIONS: Reduction of daytime wetting and urinary tract infection can be achieved regardless of the type of biofeedback used. Although symptoms improved, patients using a shorter but more intensive approach aimed at teaching control of the pelvic floor musculature were more likely to demonstrate persistent post-void residuals and abnormal flow curves. A considerable degree of enthusiasm was reported using both of these non-invasive forms of treatment.     

The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III

Recent studies suggest that the symptoms of chronic non-bacterial prostatitis (CP) or Chronic Pelvic Pain Syndrome (CPPS) may be due to or associated with pelvic floor muscle dysfunction. Therapies aimed to improve relaxation and proper use of the pelvic floor muscles such as biofeedback physical therapy and pelvic floor re-education are expected to give symptom improvement. The objective of this study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CPPS. MATERIALS AND METHODS: Between March 2000 to March 2004, 33 consecutive men were diagnosed with CP/CPPS based on history including the NIH-CPSI questionnaire and physical examination including pelvic floor muscle tonus, urinalysis, uroflowmetry with residual urine measurement and transrectal ultrasonography of the prostate. All patients participated in a pelvic floor biofeedback re-educating program. A rectal EMG probe was used to measure resting tone of the pelvic floor muscles and was helpful for instruction pelvic floor muscles contraction and relaxation. RESULTS: Two of the 33 men dropped out. In the remaining 31 men, mean age 43.9 years (range 23-70), the mean total Chronic Prostatitis Symptom Index (NIH-CPSI) changed from 23.6 (range 11-34) at baseline to 11.4 (range 1-25) after treatment (p<0.001). The mean value of the pelvic floor muscle tonus was 4.9 at diagnosis (range 2.0-10.0) and decreased to 1.7 (range 0.5-2.8) after treatment (p<0.001). CONCLUSIONS: Our study clearly demonstrates a significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS patients, leading to a significant improvement of the symptom score. The correlation between the pelvic muscle tonus results with NIH-CPSI score is highly suggestive that the pelvic floor plays an important role in the pathophysiology of CP/CPPS.     

A self-directed home biofeedback system for women with symptoms of stress, urge, and mixed incontinence.

PURPOSE: To evaluate a self-directed home biofeedback treatment system in a group of community dwelling, otherwise healthy women with symptoms of stress, urge, and mixed urinary incontinence (UI). SETTING AND SUBJECTS: Fifty-five women, aged 25 to 81 years, participated in the study. METHODS: Initial evaluation included a self-reported continence assessment, a 24-hour bladder and fluid habits diary, severity indices for stress and urge UI, and assessment of pelvic floor strength using a pneumatic biofeedback device. Subjects completed a 16-week self-directed program. Assessment and severity index data were self-reported using a continence assessment form, a 24-hour bladder habit and fluid form, and stress and urge incontinence severity indices. Strength level of the trainer, number of digital bands lit on the screen during contraction, number of sessions, and program (starter, intermediate, advanced, or maintenance) were recorded on data sheets. INSTRUMENTS: The treatment system includes an 8-minute educational and motivational video; a journal for education, instructions, and daily documentation forms; and a home biofeedback trainer with pneumatic vaginal sensors that displays the strength of pelvic muscle contraction. RESULTS: Forty-four women completed the 16-week program. At the end of treatment, 19 (43%) were dry and 16 (36%) reported 50% or more improvement in number of leaks per day, number of voids per day, or both. Women with stress leakage experienced a significant reduction in the number of incontinent episodes per day and the mean severity index of incontinence (P < .001). Participants with urge UI experienced a significant reduction in the mean number of voids per day and mean severity index for UI (P < .001). Younger subjects were more likely to improve when compared with older participants, but no significant differences were found when comparing women who take estrogen with those who do not take estrogen or when comparing those with a history of bladder surgery with those who had no previous surgery. CONCLUSIONS: These data suggest that self-selected healthy women with symptoms of urge, stress, and mixed incontinence can improve their symptoms and lower their severity index with a minimal intervention, comprehensive, self-directed home biofeedback continence system.     

Treatment of Posttraumatic Stress Disorder in Postwar Kosovo High School Students Using Mind–Body Skills Groups: A Pilot Study

This preliminary study examined whether the practice of mind-body techniques decreases symptoms of posttraumatic stress in adolescents. Posttraumatic Stress Reaction Index questionnaires were collected from 139 high school students in Kosovo who participated in a 6-week program that included meditation, biofeedback, drawings, autogenic training, guided imagery, genograms, movement, and breathing techniques. Three separate programs were held approximately 2 months apart. There was no control group. Posttraumatic stress scores significantly decreased after participation in the programs. These scores remained decreased in the 2 groups that participated in the follow-up study when compared to pretest measures. These data indicate that mind-body skills groups were effective in reducing posttraumatic stress symptoms in war-traumatized high school students.     

Self management in the treatment of ataxia: a case study in reducing ataxic tremor through relaxation and biofeedback

This study examined the effects of relaxation training and biofeedback on the ataxic tremor of an adult with an acquired brain injury. The participant was taught relaxation techniques before biofeedback was introduced. Once he was proficient in relaxation, these skills were used as a foundation for biofeedback training. Specific skills crucial to the performance of activities of daily living were trained once the participant was able to control the appropriate musculature according to an individualized criterion level. These skills included eating and the transfer of liquids in a glass. The results demonstrated that the participant learned to decrease the amount of tremor that he experienced. As a result he was better able to feed himself and to drink from a glass with less staff assistance than he had previously required.     

A modified biofeedback program for children with detrusor-sphincter dyssynergia: 5-year experience

PURPOSE: We reviewed our 5-year experience with a modified 4 to 6-session biofeedback program combining noninvasive urodynamic approaches with various psychological techniques, including externalizing the voiding problem, empowerment and praise, to treat children with detrusor-sphincter dyssynergia. MATERIALS AND METHODS: Biofeedback was performed with a urodynamics processor that enables simultaneous recording of urine flow and electromyography, and visual display of flow/electromyography activity. Initially normal and abnormal voiding were explained in a unique way and the children observed relaxation and contraction of the pelvic floor muscles while visualizing the electromyography monitor. The bladders were filled naturally and surface electrodes were placed. Psychological strategies were used to engage and motivate the children to achieve maximal cooperation. The children voided while attempting relaxation and post-void residual urine volume was measured by bladder scan. Special and specific praise was provided for progress and increasing self-esteem. Patients returned monthly to review these concepts and practice voiding. RESULTS: Of 87 children 77 completed the program, including 7 boys and 70 girls 3 to 17 years old (mean age 7.8) who required an average of 4.7 sessions (median 4). Results were achieved within 6 sessions in 82% of cases. Of the 77 children 59 (76%) had recurrent urinary tract infections, 38 (49%) had associated bladder instability, 19 (24%) had vesicoureteral reflux and 44 (58%) had constipation. Subjectively 47 patients (61%) reported pronounced improvement in urinary symptoms, while another 24 (32%) reported moderate improvement after biofeedback training. Objectively 47 children (61%) had normal flow with minimal electromyography activity during voiding and a normal post-void residual urine of less than 20% voided volume (p <0.002). In 28 cases (36%) flow studies improved (p <0.03) but post-void residual urine remained elevated. Vesicoureteral reflux resolved in 9 cases after biofeedback training. This approach was equally successful in children in all age groups. Those with more than a 2-year history of symptoms, poor bladder emptying and severe constipation had only moderate improvement. CONCLUSIONS: The modified biofeedback program including appropriate explanations and psychological approaches appeared effective for treating 92% of children with detrusor-sphincter dyssynergia. It is less invasive and requires less time than traditional methods, and patients are more compliant with treatment.     

Relaxation therapies for asthma: a systematic review

BACKGROUND: Emotional stress can either precipitate or exacerbate both acute and chronic asthma. There is a large body of literature available on the use of relaxation techniques for the treatment of asthma symptoms. The aim of this systematic review was to determine if there is any evidence for or against the clinical efficacy of such interventions. METHODS: Four independent literature searches were performed on Medline, Cochrane Library, CISCOM, and Embase. Only randomised clinical trials (RCTs) were included. There were no restrictions on the language of publication. The data from trials that statistically compared the treatment group with that of the control were extracted in a standardised predefined manner and assessed critically by two independent reviewers. RESULTS: Fifteen trials were identified, of which nine compared the treatment group with the control group appropriately. Five RCTs tested progressive muscle relaxation or mental and muscular relaxation, two of which showed significant effects of therapy. One RCT investigating hypnotherapy, one of autogenic training, and two of biofeedback techniques revealed no therapeutic effects. Overall, the methodological quality of the studies was poor. CONCLUSIONS: There is a lack of evidence for the efficacy of relaxation therapies in the management of asthma. This deficiency is due to the poor methodology of the studies as well as the inherent problems of conducting such trials. There is some evidence that muscular relaxation improves lung function of patients with asthma but no evidence for any other relaxation technique.     

Increasing functional communication through relaxation training and neuromuscular feedback.

The following research examined the effects of behavioural relaxation training and biofeedback on ataxic tremor of an adult with acquired brain injury. The participant was taught relaxation techniques before biofeedback was introduced. Once he was proficient in relaxation, these skills were then used as a foundation for biofeedback training. Specific skills, facilitating the use of a letter board, were taught when the participant was able to relax the appropriate musculature to criterion. The results demonstrated that the participant learned how to significantly decrease the severity of tremor. As a result, he became more proficient at communicating via his letter board. Collateral effects were increased attempts at communication and fewer episodes of anger.     

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 role of pelvic-floor therapy in the treatment of lower urinary tract dysfunctions in children

The pelvic-floor is under voluntary control and plays an important role in the pathophysiology of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to influence the activity of the pelvic-floor during voiding: proprioceptive exercises of the pelvic-floor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic-floor by a curve on a display (relaxation biofeedback), observation of the flow curve during voiding (uroflow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic-floor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed.     

Role of behavioral changes and biofeedback in urology

Voiding disorders are common in urological patients. Pelvic floor dysfunction may result from overtraining pelvic floor muscles in an attempt to prevent leaking. This can further cause bladder dysfunction or weakening the pelvic floor muscles. Pelvic floor dysfunction or insufficient relaxation of the pelvic floor results in hesitancy, intermittency, and high postvoid residuals (PVR). Behavioral changes and biofeedback play a key role in urologic problems including pelvic pain, irritative voiding symptoms, recurrent urinary tract infections, and incontinence. Biofeedback involves using electrodes to transduce muscle potentials into auditory or visual signals; patients learn to increase or decrease voluntary muscle activity. Conservative behavioral and biofeedback treatments are safe and effective interventions that should be more readily available to patients as a first-line treatment for voiding dysfunction. Patient education may take time but has higher long-term success and makes the patient more responsible and less passive regarding their condition.     

The Effectiveness of Electromyographic Biofeedback as Part of a Meniscal Repair Rehabilitation Programme

The objective of the study was to assess the effectiveness of using electromyographic biofeedback in the early stages of rehabilitation after meniscal repair. In this randomised, controlled, parallel group study, the evolution of patients with meniscal lesions treated by meniscal suture who received (study group, n = 33) or did not receive (control group, n = 31) electromyographic biofeedback as part of their early rehabilitation programme has been compared. A total of 64 patients with previous meniscal repair participated in the study. The patients received a baseline assessment (after 1 postoperative week) and a follow-up (after 8 postoperative weeks) consisting of surface electromyography, dynamometry of thigh muscles and the assessment of the Knee injury and Osteoarthritis Outcome Score (KOOS). The electrical potential in contraction and the speed for contraction and relaxation for all monitored muscles increased significantly in the study group (p < 0.05). The difference between groups in the assessed score was significant for sport and recreational function (p < 0.05). The strength of the thigh muscles was not significantly influenced by the introduction of electromyographic biofeedback (EMG- BFB) in the rehabilitation programme. Electromyographic biofeedback helped patients to control their muscles after meniscal repair to accomplish physical activities that require better neuromuscular coordination and control. For these reasons, one may consider electromyographic biofeedback as an important component of rehabilitation after meniscal repair.

Key Points

• Exercises during the early phases of rehabilitation after meniscal repair are difficult to perform because of pain, oedema, and possibly a disruption in normal joint receptor activity.
• Electromyographic biofeedback is a painless, non-invasive method that can be used in muscle recovery after meniscal repair and enhances the rehabilitation process, especially related to muscular function.
• The rehabilitation programme that includes electromyographic biofeedback after meniscal repair increased the speed of muscle response to acoustic stimulation in both the initiation of contraction (onset time) and relaxation (offset time) and, also, the capacity of performing some specific physical acti-vities after 8 weeks of rehabilitation (according to KOOS values).
• Electromyographic biofeedback is not responsible for the decrease in pain, swelling or other postoperative symptoms but it is important in order to help the patient to conduct the activities which require neuromuscular coordination and muscle control.

Key words: Knee, injury, physical therapy     

Injuries to the lower back in elite fast bowlers: acute stress changes on MRI predict stress fracture

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.     

Efficacy of biofeedback in the treatment of urinary stress incontinence

Thirty-seven women with stress incontinence were given biofeedback instruction on how to perform pelvic floor exercises correctly. After 3 months with home exercises 31 patients performed a new standardized pad-weighing test: 39% were objectively cured and 42% improved. After a mean of 2 years 15 patients were evaluated with another pad-weighing test: 27% were now objectively cured and 47% improved. A questionnaire showed that 78% had an exact knowledge about the location of the pelvic floor muscles and 47% were satisfied with their present situation, but only 58% performed daily exercises.Editorial Comment: Treatment modalities for female urinary incontinence, as for any other medical condition, need to be validated prior to widespread use. The methods chosen to assess treatment also need to be acknowledged and deemed acceptable outcome measures. The study presents an objective assessment of biofeedback in the treatment of genuine stress incontinence. The authors report a 39% cure rate and a 42% improvement rate at 2 years, suggesting that biofeedback is a viable means of conservative management of genuine stress incontinence. Unfortunately, the study design lacks significant power on which to draw significant conclusions, as only 15 of 37 patients continued treatment for as long as 2 years. Compliance with treatment, however, is a factor found with any form of conservative (medical therapy) and, as such, the dropout rate experienced in this cohort of patients is not unexpected.     

Effects of magnetic stimulation in the treatment of pelvic floor dysfunction

OBJECTIVE: To correlate, in a pilot study, the clinical results of extracorporeal magnetic innervation therapy (ExMI) of the pelvic floor muscles with functional changes in the pelvic floor musculature, urodynamics and quality of life. PATIENTS AND METHODS: In all, 74 patients (65 women and nine men) with urge incontinence, urgency/frequency, stress incontinence, mixed incontinence and defecation problems were included in a prospective study of ExMI using a 'electromagnetic chair'. All patients were treated twice weekly for 8 weeks. Digital palpation and biofeedback with a vaginal or anal probe were used for registration of the pelvic floor musculature. A urodynamic evaluation, a voiding diary, a pad-test, the King's Health Questionnaire (KHQ) and a visual analogue scale (VAS) were completed by the patient at baseline and at the end of the study. RESULTS: In the group as a whole, there were no significant differences in the voiding diary, pad-test, quality of life, VAS score, biofeedback registration and urodynamics before and after treatment. Additional stratification was applied to the total patient group, related to the pretreatment rest tone of the pelvic floor, the basal amplitude registered on electromyography, to age and to previous treatments. However, there were no significant differences in the data before and after treatment within all subgroups (stress incontinence, urge incontinence, urgency/frequency, defecation problems, overactive pelvic floor, age, previous treatments), except for the KHQ domain of 'role limitations', where there was a significant improvement in all groups. CONCLUSION: ExMI did not change pelvic floor function in the present patients. The varying outcomes of several studies on ExMI stress the need for critical studies on the effect and the mode of action of electrostimulation and magnetic stimulation. In our opinion 'the chair' is suitable to train awareness of the location of the pelvic floor. However, active pelvic floor muscle exercises remain essential.     

Pelvic floor spasms in children: an unknown condition responding well to pelvic floor therapy

OBJECTIVE: During a study period of 4 years, 21 children are seen for night time pelvic pain. These children typical wake up in the middle of the night with severe lower abdominal or perineal pain. During day some of them suffer urge syndrome. During urodynamic investigation extremely high pelvic floor activity as recorded by high urethral pressure was observed in these children. We therefore started pelvic floor relaxation biofeedback in these children. METHODS: All children diagnosed with pelvic floor spasms underwent biofeedback pelvic floor relaxation therapy in order to learn them to counteract pelvic pain due to these spasms. In those girls in whom detrusor hyperactivity was seen on urodynamics concomitant anticholinergic treatment was given (oxybutynin). RESULTS: Between January 1998 and January 2002 symptomatic pelvic floor spasms were diagnosed in 21 children (19 girls/2 boys). Pelvic floor relaxation biofeedback was successful for treatment of this condition in 17 of 21 children. Mean duration of therapy was 3 months (12 weekly sessions) and on long term follow-up relapse was seen in 3 of 17 successfully treated children. 10 of 17 successfully treated children received anticholinergics. CONCLUSION: Pelvic floor spasms in children (which can be secondary to detrusor overactivity) respond well to pelvic floor relaxation therapy.     

Treatment of Female Urinary Incontinence with EMG-Controlled Biofeedback Home Training

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.     

Anal stenosis: use of an algorithm to provide a tension‐free anoplasty

Background: Anal stenosis is a debilitating condition that often is iatrogenic in cause. Various surgical procedures to manage this problem have been described. The present study evaluates the use of different anoplasty techniques in a series of 11 patients with anal stenosis. To the best of the authors' knowledge, this is the first study to provide a stepwise algorithm for the anoplasty techniques used. Methods: A series of 11 patients were evaluated for presenting symptoms, cause of anal stenosis, type of anoplasty used, complications and post‐operative success in relieving symptoms. All operations were performed by one surgeon in three hospitals, and were followed up by the same surgeon and by a surgical registrar. Results: The most common presenting symptoms were constipation and decreasing calibre of stool. The main causes of anal stenosis were previous surgery, neoplasia and fissure. Transverse closure, Y‐V and diamond advancement flaps were used in an escalating manner to deal with increasing severity of stenosis. All 11 patients had some level of improvement in symptoms post‐operatively. There were no long‐term complications. Conclusion: Anoplasty is a safe and successful option in the treatment of anal stenosis, and this stepwise algorithm takes the guesswork out of choosing the most appropriate procedure for each patient.     

Treatment of constipation in adults associated with idiopathic megarectum by behavioural retraining including biofeedback

Background Constipation in adults associated with a grossly dilated rectum and recurrent faecal impaction, idiopathic megarectum, is rare. The aetiology of idiopathic megarectum is unknown, but may involve neuromuscular or behavioural factors. It is unknown whether the condition is reversible. This study aimed to determine the efficacy of behavioural therapy, including biofeedback, in such patients. Methods Six patients (4 female; median age 27) with a history of rectal faecal impaction and a grossly dilated rectum on radiological examination were evaluated by structured questionnaire before, immediately after biofeedback therapy, and on follow‐up. Physiological testing was performed before treatment, and 2 patients were evaluated by repeat physiological testing and contrast radiology on follow‐up. Results On median follow‐up of 18 months (range 11–27), five patients felt major and one patient minor improvement in symptoms, including two with complete symptom relief. Four patients came off laxatives without recurrent faecal impaction. In the 2 studied patients rectal size did not appear to decrease. Conclusion Behavioural retraining, including biofeedback, improved symptoms in most patients with idiopathic megarectum. In some patients symptoms completely resolved, without the need for laxatives. Although further studies are necessary in terms of both larger number of patients and longer follow‐up period, behavioural treatment may be useful for such patients.     

The role of biofeedback and relaxation therapy in arterial occlusive disease

Eleven patients with chronic arterial occlusive disease and intermittent claudication were treated with biofeedback-relaxation therapy in an attempt to increase walking time by improving peripheral blood flow. Criteria for admission to the study included (1) participation in an exercise program without improvement in symptoms (2) a maximal treadmill walking time (MWT) of <5 min and (3) an ankle blood pressure of <60 mm Hg immediately postexercise. Patients were randomized into two groups: Group I entered biofeedback training immediately, and Group II served as controls for 3 months prior to undergoing the same treatment protocol as Group I. Patients were taught EMG and skin temperature feedback during 30 1-h training sessions over a 13-week period. Following biofeedback therapy all patients in Group I significantly increased their MWT (P < 0.001) while patients in the control Group (II) showed minimal improvement in MWT. After undergoing biofeedback therapy, Group II also improved their MWT. At the completion of the study, 9 of 11 patients walked >8 min. The improved MWT was associated with a fall in resting (P < 0.05) and exercise (P < 0.01) arm systolic blood pressure. Both the exercise ankle blood pressure (P < 0.05) and exercise ankle/arm blood pressure ratio (P < 0.01) increased significantly following biofeedback therapy, suggesting a reduction in resistance around the site of occlusion. Our findings indicate that biofeedback training may be an effective nonoperative treatment for selected patients with arterial occlusive disease and intermittent claudication.