Biofeedback therapy for chronic constipation

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Chinese Journal of clinical health, 2009, (2): 205-7 ()With the change of people's diet structure and the influence of psychological and soc

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Chinese Journal of clinical health, 2009, (2): 205-7 ()

With the change of people's diet structure and the influence of psychological and social factors, constipation has become one of the important factors that affect the quality of life of modern people. From the analysis of epidemiological data with constipation in functional constipation (functional constipation, FC) accounted for about 5O%[1]. Functional constipation mechanism is complex, the treatment is tricky. The long-term laxative use not only poor efficacy, and easy cause of bowel disease and cathartic colon melanosis and surgical treatment are postoperative complications such as diarrhea, fecal incontinence and recurrence problems. However, the emerging biofeedback therapy has the advantages of simple, non-invasive, no side effects, easy to endure, low cost of treatment, outpatient treatment, etc., thus opening up a new way to treat constipation.

1 biofeedback

Biofeedback therapy, which was first established in 60s, is a combination of relaxation therapy and biofeedback. In fact, it is a kind of treatment and training method to control the involuntary visceral function by means of self suggestion and self hypnosis. Application of biofeedback electronic instruments in the course of treatment, the human body under normal circumstances are not aware of the physiological functions (such as EMG, EEG, skin temperature, heart rate and blood pressure) to be recorded. And converted into a feedback sound light and signal can be observed, the subjects to learn to regulate their body organs function involuntary and other bodily functions according to the feedback signal to achieve the purpose of combating the disease. It is mainly used in the treatment of hypertension, constipation, fecal incontinence, nervous headache and other diseases. Biofeedback methods include: EMG mediated biofeedback, pressure measurement mediated biofeedback, and other biofeedback.

Biofeedback therapy has been studied for decades in foreign countries, and is the first choice for the treatment of functional bowel disorders ([2]). In 1985, some European and American countries in the consensus: surgeons should use electromyographic biofeedback training system in patients with anal sphincter relaxation to treat constipation, this kind of "export obstruction" of the abnormal contraction of anal sphincter surgery using only previous treatment. At the same time by the same means of training and self adjustment in the cause for those anal sphincter relaxation fecal incontinence cases, also can enhance muscle strength and cure pelvic fecal incontinence. Incontinence used in children caused by congenital anal atresia after surgery is very effective. Accumulated rich experience in this area

The last 10 years, research on behavioral therapy of Gastroenterology has been greatly developed, which could be attributed to the effect of biofeedback technique in this field is more and more big, especially in some developed countries have the biofeedback training as a conventional method, is widely used in gastrointestinal dysfunction, such as incontinence, IBS sign, especially in the treatment of constipation in patients with infarction type [3] export.

2 constipation

According to the Rome III standard [4], defined as: constipation, difficult defecation, hard stool, defecation frequency decrease or defecation imcompletely; every week 3 times, < completely defecation; daily defecation quantity < 35 g; the whole gastrointestinal or colonic transit time. Gastrointestinal transit status is recommended by the international general Bristol stool classification to determine, in line with the criteria for constipation is BristolI~ type ii.

Constipation is a common symptom, seriously affecting people's quality of life, and is closely correlated with the occurrence of colon cancer, breast disease, Alzheimer's disease etc.. According to etiology, can be divided into functional and organic constipation. The United States complained of patients with constipation as more than 2 million 500 thousand times, a randomized, stratified survey of the Beijing region of China's population aged 18~7O years showed that the prevalence of chronic constipation was 6.07%, and the investigation of other people over the age of 6O confirmed that the incidence rate of 7.3%~20.39%, along with the age growth rate increased significantly [5]. Therefore, early prevention and reasonable treatment will greatly reduce the social burden and improve people's quality of life.

2.1 pathophysiology of constipation

Constipation refers to dry stool, defecation difficulties or not. And reduce the number of bowel movements and other clinical symptoms, the interference caused by defecation reflex. Defecation reflex is not only an unconscious reflex activity, but also controlled by the brain's higher central consciousness. Defecation reflex stool into the rectum, rectal mechanical expansion, rectum pressure increased by rectal wall reflection, sphincter tension decreased, anal pressure decreased. Pelvic floor muscle, external sphincter reflex contraction to prevent fecal incontinence. At the same time. Fecal compression pelvic floor stimulation defecation receptors, impulses to the cerebral cortex produce meaning, such as environmental permit. Can consciously lift pelvic muscle and sphincter reflex contraction, complete defecation in other muscles and abdominal pressure assistance. Physiology that body with a non conscious layer of subcortical central self regulating and maintaining homeostasis function, and biofeedback to operating conditions as the theoretical basis, so the relationship between constipation and defecation reflex. The pathophysiological basis of biofeedback treatment of constipation.

2.2 diagnostic criteria and classification of functional constipation

To exclude organic diseases caused by constipation, can be judged according to Rome criteria for functional constipation: [4] symptom appeared in at least 6 months before diagnosis, nearly 3 months of symptoms have the following characteristics: (1) must meet the following two or more points: 1. At least 25% of the defecation feel laborious; at least 25% of the defecation it is hard to block or 3; at least 25% of the defecation endless feeling; the at least 25% defecation anus and rectum obstruction / obstruction; and at least 25% of the need to help defecation techniques (such as a finger to help defecation, defecation and pelvic support); < 3; (2) do not use laxative almost no soft; (3) there is no evidence sufficient to diagnose IBS.

According to the type of constipation, cause the intestinal and anorectal function and dynamic characteristics of constipation were divided into 3 types: [6], slow transit constipation (Slow transit, constipation, STC), obstructive constipation (outlet obstructive constipation, OOC) and mixed constipation (mixed constipation, MC) three. STC is due to the colonic motility disorder, the intestinal contents remained in the colon or colon through slow constipation, also called colon weakness, this is the most common type of FC, its clinical features are to reduce the number of bowel movements (< 3 times / week), no meaning, difficult defecation and hard fecal matter (1 ~ Bristol 2). OOC is the first choice of promoting agent, and the normal colonic transit function is related to the dysfunction of the anal sphincter and the abnormal rectal reflex threshold. Patients often complain of defecation, anal straining feeling endless defecation, defecation, stool less hard or soft in forming. In children, women and the elderly to see, can choose the treatment of biofeedback training; MC system both colonic slow transmission characteristics, while the presence of anorectal sensory or motility disorders, or both are not typical, It differs from man to man. treatment.

2.3 diagnosis of constipation

Attention should be paid to the acquisition of history, to determine the possible etiology. Through a detailed examination of the history, doctors should be aware of what the patient referred to as "constipation" refers to what accompanied symptoms and predisposing factors, such as the preliminary determination of the type and severity of constipation. According to the etiology, constipation can be divided into functional and organic, the latter by the primary intestinal pathological changes such as tumor or muscle and nerve lesions caused by abnormal and systemic or metabolic disease caused by bowel movement, should be easily diagnosed in clinic. For functional constipation, its etiology and predisposing factors are complex, the diet is not the only factor, many patients with a common complaint of cellulose did not improve symptoms.

Effect of defecation process caused many constipation factors, in addition to food intake, low fiber diet, also including mental, psychological factors and stress, abuse of laxatives etc.. In recent years studies on neural gastroenterology suggest a brain gut axis and nervous system disorders in STC, and observed gastrointestinal motility in Cajal cells of this kind of colonic pacing in patients with constipation or muscle submucosal interstitial cells (interstitial cells of Cajal, ICC) reduce the number of [7-9], with abnormal ultrastructure. More recent studies have used fluorescence in situ hybridization to detect abnormal STC in first, 8, 17 and XY chromosomes in some patients with [10].

2.4 diagnostic procedures

For patients with chronic constipation, the first thing to note whether the alarm symptoms (such as weight loss, anemia, bloody stool, abdominal cramps, abdominal mass, etc.) and evidence for the existence of other systemic disorders. Colonoscopy should be performed in the presence of 40 years of age, a history of chronic constipation, and a worsening of symptoms in the short term. For the long-term abuse of laxatives, colonoscopy can determine whether there is a cathartic colon (cathartic colon). Barium enema in the diagnosis of Hirschsprung's disease. If suspected of outlet obstruction constipation, DRE and defecography is necessary. When necessary, can choose dynamic detection of [11] tube.

3 biofeedback and chronic constipation

3.1 principles and methods of biofeedback in the treatment of constipation

Biofeedback treatment of constipation by manometry and electromyography equipment, the functional status in patients with pelvic floor muscle intuitively perceive the defecation, learn how to relax pelvic floor muscles during defecation, and increased intra-abdominal pressure, in order to achieve the purpose of defecation. Before the treatment to the patient to explain in detail the human colonic and anorectal and pelvic floor muscle of normal anatomy and physiological function and normal defecation mechanism. The patients to master the biological feedback mechanism and its purpose; and then the treatment instrument and patients after connecting to the patient, clear instrument shows curve significance, and points out that the patients in the abnormal the resting state of breath holding and defecate, patiently tell the patient how to control the sphincter contraction, encourage them to try, once the right move should be encouraged. Finally, the patient in the absence of medical help, the face of the instrument to practice, until 3 consecutive normal defecation. Of course, the efficacy of biofeedback is associated with improvements in symptoms and mental health and quality of life in patients with constipation [12]. The compliance of the patients and whether they can complete the course of treatment are also the main factors affecting the efficacy, but not related to other pelvic floor lesions [13].

3.2 clinical application

Application of 3.2.1 biofeedback in the treatment of outlet obstructive constipation caused by pelvic floor dysfunction

Outlet obstruction constipation caused by external anal sphincter disorders. Rectal sensitivity decreased, anorectal reflex, anorectal motility abnormalities can lead to constipation. . biofeedback therapy is not coordinated training method to correct the defecation behavior, mainly for the treatment of outlet obstruction constipation defecation disorder and pelvic floor muscles, anal sphincter of external anal sphincter contraction leads to the contradiction: there have been many reports in the United States, constipation affects about 45 thousand people's health. Patients are mainly women and the elderly, the data shows that about 50% of the patients with pelvic floor dysfunction caused by. The application of biofeedback in the treatment of pelvic floor dysfunction is feasible. Foreign Battaglia [14] observed 24 cases of epilepsy. In the 1 years of observation, 50% effective biofeedback pelvic floor dysfunction patients, 20% patients with slow transit constipation effectively, observation showed that the long-term efficacy of biofeedback pelvic floor dysfunction patients, but most just short-term effect of slow transit type.

The Chen Yanmin [15] observation of 32 patients with pelvic floor muscle functional constipation disorders, rectal electrical and EMG assessment, there are contradictions between anterior abdominal oblique - pelvic muscle, and contraction decreased significantly. Biofeedback treatment of choice, 2 ~ 3 times a week, January. Treatment of biofeedback therapy in patients with constipation after a week of independent defecation from 0.8 before treatment to 3.8 + 0.3 + 1.1, the cases of l0 patients were followed up for 1 years, 8 cases of normal defecation times after treatment, all patients with abdominal and pelvic floor muscle anterior oblique contradiction the movement disappeared and motion amplitude increased > 50mmHg. The analysis of abnormal defecation dysfunction of pelvic floor contraction is not a muscle disorder, abnormal muscle spasm is not continuous, but the overall reflex relaxation of striated muscle dysfunction. You can recognize the functional constipation of pelvic floor muscle dysfunction in patients with anorectal motility disorders, contradiction of abdominal anterior oblique muscle and pelvic floor muscles, biofeedback therapy improves pelvic floor muscle function.

Application of 3.2.2 biofeedback in slow transit constipation

Patients with slow transit constipation by isotope, pressure proof, some patients with postprandial intestinal intraluminal pressure is not increased, 24h manometry showed that exercise reduced the group. Biofeedback can improve the intestinal activity of the brain, and many people believe that it is also effective in the treatment of slow transit constipation.

Foreign Emmanuel [16] was observed in 49 patients. To show the effect of biofeedback treatment is greater than the pelvic floor biofeedback treatment results, success is the innervation of the gut and improve brain activity and improve transmission capacity of the link blocked this effect only, in the intestine, but have no influence on cardiovascular autonomic. Based on the above analysis, it can be concluded that the treatment of slow transit constipation is effective.

In short, under the guidance of EMG biofeedback training on defecation disorders caused by abnormal anorectal motility treatment is a new medical mode. Foreign reports have higher success rate and efficiency of [17], and more economical than other treatments. At present only a few medical units have this technology. The clinical application and effect has been preliminary encouraging. Although the application of this technology has been mature, but the treatment of the observation, there is no unified index, such as the course of treatment, efficacy, indications, contraindication and so on. Strengthen the multi center, large sample of collaborative observation, to explore a set of suitable for Chinese people more perfect the treatment plan is the next research direction.

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