Home-based biofeedback therapy helpful for constipation

Last Updated: 2018-10-03

By Scott Baltic

NEW YORK (Reuters Health) - In treating dyssynergic defecation, home-based biofeedback therapy is as good as the office-based version, relieving chronic constipation in about 70% of patients, a new study has found.

Home-based biofeedback, using a new portable biofeedback device and probes, was also significantly less expensive than the more common office-based approach.

"Dyssynergic defecation affects millions of people (and) causes chronic constipation in one-third of patients," lead author Dr. Satish Rao of Augusta University Medical Center in Georgia told Reuters Health by email. "Giving them repeated laxatives and other drugs often fails."

"Home biofeedback is effective and safe, and as good as office biofeedback therapy," he continued, adding that, "patients can learn this treatment with minimal assistance, and through this change their defecation behavior and achieve a cure or significant improvement in their chronic disabling constipation."

"Our findings can be a game changer in the management of these patients," Dr. Rao said.

Biofeedback therapy for dyssynergic defecation has been shown to be more effective than laxatives or relaxation therapy and has been endorsed by U.S. and European medical societies.

But office-based biofeedback therapy is not widely available, is labor intensive for patients and therapists, requires multiple office visits, and in the U.S. is often not covered by insurance, Dr. Rao and colleagues note in The Lancet Gastroenterology & Hepatology, online September 17.

Home biofeedback treatment "could substantially broaden the availability of biofeedback therapy and should be the preferred setting," they write.

To compare the two treatment types, the team conducted a randomized, parallel-arm trial at the University of Iowa, enrolling adults who had been referred to a tertiary-care center because of constipation.

Participants were given advice on bowel habits, exercise, laxatives, dietary fiber and fluid intake, and all were advised to attempt a bowel movement for five minutes, twice per day, 30 minutes after eating, regardless of their urge to defecate. A nurse therapist taught patients how to improve their push effort with postural and diaphragmatic breathing techniques, which were to be practiced at home for 15 minutes, three times per day.

Participants were advised to take magnesium hydroxide or magnesium gluconate daily and also received recommendations on rescue laxatives and other measures in case of severe constipation.

Patients assigned to office-based biofeedback had an initial training session followed by one-hour sessions every two weeks at the hospital, up to a maximum of six therapy sessions over three months.

The biofeedback therapy consisted of three components: diaphragmatic breathing techniques to improve the push effort; training to use increased push effort to improve recto-anal coordination, along with anal relaxation; and training to efficiently expel a 50 mL artificial stool over three attempts.

Patients randomized to home-based biofeedback attended one session to receive instructions on how to use the home-training device, which consisted of a reusable dual-sensor rectal probe connected to a handheld pressure monitor that displayed the patient's response.

The patient then was asked to sit on a commode and attempt 10-15 push maneuvers while monitoring the anal and rectal pressure changes on the handheld device. Patients were asked to insert the probe at least twice daily, practice for 20 minutes, and record the results.

They returned to the hospital for follow-up visits after four and eight weeks to have the device's sensitivity adjusted and new goals set, depending on progress.

Of 100 participants enrolled (96 women), 83 completed the study (45 of 50 in the office-based arm and 38 of 50 in the home-based arm).

In both treatment groups, the number of complete spontaneous bowel movements per week increased significantly versus baseline, as did satisfaction with bowel function (p<0.0001 for both groups and both outcomes). Home-based biofeedback therapy was non-inferior to office-based therapy for both outcomes.

Treatment responders were defined post hoc as those with normalization of dyssynergic defecation and an increased number of complete spontaneous bowel movements per week by three months. By that standard, 68% of patients in the home-based group and 70% in the office-based group were classified as responders.

The cost of home-based biofeedback was significantly lower, with a median of $1,082 versus $1,943 for office-based treatment. These totals included estimates for transportation costs, travel time and time lost from work.

In an editorial, Drs. Henriette Heinrich of University Hospital Zurich and Mark Fox of St. Claraspital in Basel, both in Switzerland, call the trial "a well-designed controlled non-inferiority study" and noted that "office-based biofeedback therapy is invasive, expensive, and time consuming."

However, they caution, "the diagnosis of dyssynergic defecation is controversial. When based on quantitative analysis of manometry or defecography data, more than half of healthy volunteers had findings consistent with dyssynergic defecation."

Still, they add, "Training in the comfort of home seems likely to alleviate feelings of awkwardness and embarrassment that are often encountered in the office setting, and might improve motivation and adherence."

Further, "home-based treatment allows more frequent biofeedback sessions, which might shorten the time to response and improve efficacy . . . We see few barriers to implementation, and we hope that increased availability of home-based treatment will facilitate access to an effective treatment for this important and common condition."

Dr. Darren Brenner of Northwestern University's Feinberg School of Medicine in Chicago, who studies gastrointestinal-motility disorders, told Reuters Health by email that given the minimal training the home-based patients received, the study's results are "quite impressive."

"If it takes minimal in-office training to obtain the results seen in this study, I believe this is a tool which can be easily implemented into academic practices and likely to primary GI-based practices as well," said Dr. Brenner, who was not involved in the study.

Dr. Brenner does see a few obstacles to widespread use of the home-based approach, however.

"Unfortunately, there remains a knowledge gap with it comes to this disorder," he said. Practicing physicians need to understand dyssynergic defecation better, test for it earlier and explain the condition and the biofeedback process well enough to patients that they will buy into the therapy.

"At its base level, we are really telling people that the muscles in their bottoms don't work, and we are going to use anal catheters instead of laxatives and other medications to fix it," Dr. Brenner explained. "Imagine your first reaction to that type of information."

Another potential barrier is the patient's time commitment. Dr. Brenner pointed out that in-office treatment was one hour every other week for 12 weeks. In contrast, the home-based approach was at least 20 minutes twice a day for 12 weeks.

The study population was "highly motivated to participate and I'm not sure an average population would do the same," Dr. Brenner said.

The study did not have commercial funding. Dr. Rao holds a patent for the handheld pressure monitor and software display used for home-based biofeedback in this study.

SOURCE: https://bit.ly/2zOhWqJ and https://bit.ly/2OvkdyX

Lancet Gastroenterol Hepatol 2018.