Biofeedback Therapy A nurse led management service for functional bowel disorders Brigitte Collins Lead Nurse BSc, MSc GI Nursing, Dip/Hypnotherapy St Marks Hospital
Is biofeedback necessary? Conservative treatments are not helpful to everyone Adverse affects on quality of life 60m per year on laxatives (PPA 2007) Variable surgical results UK survey of 731 women estimated that 8.2% - 52% will suffer with constipation (Probert et al 1995) FI affects over 10% adults (Whitehead et al 2009) with 1-2% affected by faecal incontinence on a daily or weekly basis (Perry et al 2002)
What is biofeedback? Whatever you want it to be? Behavioural/Holistic approach Learning through reinforcement Re-education tool information is relayed subconscious Patient actively involved in making a change in function Non surgical and non-invasive
The St Mark s biofeedback service Lead Nurse, 4 CNS, I physiotherapist Approx 1,000 new patients per year 1 hour new appointment, 45 mins follow up F/UPS 4-6 weeks with up to 5 appointments 70-75% discharged directly, no medical input Access to gastroenterologists, colorectal surgeons, gynaecologist, psychiatrist, full range of tests.
Complex cases with high psychopathology such as eating disorders, abuse, PD, psychotic/delusional states The St Mark s biofeedback service Faecal Incontinence Obstetric Urgency IBS IBD Urgency Anterior resection syndrome Constipation and evacuatory/defaecatory disorders Slow transit constipation Idiopathic constipation Megarectum SRUS Rectocele Rectal prolapse Ileo-anal pouch IBS IBD
What tests do we do? Constipation/Evacuatory Transit x-ray If indicated defaecating Proctogram Symptom and QOL questionnaire with PAC-QOL (Marquis et al 2005) Faecal Incontinence Anorectal Physiology Endoanal Ultrasound Symptom and QOL questionnaire with ICIQ-B (Cotterill et al 2008)
Aims of the service Comprehensive assessment identifying symptoms, problems, concerns, anxieties and quality of life Based on assessment aim is to increase insight and ability to cope and normalise bowel function Providing strategies with an individualised package of care Several components, no one treatment fits all
Components of the treatment Account of biofeedback and aim Education Digestive tract/defaecatory process Normal bowel activity Results of investigations Explanation of symptoms Bowel & muscle retraining Teach new skills and strategies Predictable schedule for defaecation Defaecatory dynamics through rectal balloon expulsion Gastrocolic response/bowel habit Evacuation posture Sphincter exercises/home programme Urge resistance Computer biofeedback Electrical stimulation
Urgency with rapid fatigue
Sustained squeeze - no urgency
Stimulation
Aims of the Service Diet Same advice not always beneficial Reduce/increase fibre (Lauti et al 2009, Bliss et al 2001) Caffeine, sweeteners, alcohol Regular eating Probiotics FODMAP Review medication Alternatives for constipation/ faecal incontinence Laxatives Evacuation aids/suppositories Loperamide Stool bulking agents
Aims of the Service Psychological support Complex Abuse (Longstreth et al 2006, Drossman et al 1990) Revealed in BFB/run simultaneously Coping mechanism/emotional support/reduce anxiety Access to psychological medicine team for ourselves Taylors research (2009) Products for management Anal plugs Pads Products for odour control Skin care products Rectal Irrigation (Christensen 2006) Qufora
Irrigation
Qufora
Efficacy of biofeedback therapy Symptomatic improvement has varied between 44% up to 100% in several uncontrolled trials (Heymen et al 2003) Studies in adults suggest biofeedback to be effective in 70% of patients with long term benefits (Norton 2008) Last few years there have been several randomised controlled trials (Chiaironi et al 2006, Rao et al 2008, Heymen et al 2007, Rao et al 2010) Significant differences in methods, in end points and outcomes. However all concluded biofeedback therapy to be superior to controlled treatment approaches. Cochrane review 2012 also concluded that biofeedback therapy was of more benefit than other interventions and instruments Nice guidance for faecal incontinence and IBS.
St Marks audit An audit of the last 615 patients 84% improvement/cured Patients rating of change = median 3/5 Satisfaction of results = median 8/10 If only I had come here years ago I have my life back I feel that I am now in control
Research, audit and new developments Research RCT of reflexology compare to biofeedback therapy (Woodward and Norton 2010) Pilot study of PTNS for constipation (Collins and Norton 2010) funding applied for RCT Study of prevalence in eating disorders completed awaiting results Qualitative/phenomenological study for anterior resection syndrome PTNS and fissure pilot study
Research, audit and new developments Audit Audit on the qufora mini irrigation Reviewed 50 patients with 74% advising that the system was good 58% showing improvement in symptoms Fibre audit for F.I. New developments Developing pathways Hypnosis service Clinical psychologist
Conclusion Behavioural/holistic approach, non-surgical and non-invasive Holistic approach takes time and individualised care Many components required to address individual problems 2012 Cochrane review/biofeedback does confer more benefit than other interventions 84% Improvement Biofeedback can be what you want it to be