title: Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation.
abstract: BACKGROUND
  Although behavioural treatment (biofeedback) successfully treats the pelvic floor abnormalities in patients with idiopathic constipation, many patients also normalise their impaired bowel frequency. We postulated that a response may be associated with altered cerebral outflow via extrinsic autonomic nerves to the gut. We investigated whether treatment changes extrinsic innervation, using mucosal laser Doppler flowmetry, whether autonomic changes are gut specific, and whether it changes gut transit.
  
  
  METHODS
  Forty nine patients (44 female, mean age 39 years) with idiopathic constipation were studied before and after biofeedback treatment (mean five sessions). Rectal mucosal blood flow was measured by laser Doppler flowmetry to assess direct extrinsic gut nerve autonomic activity. To assess general autonomic activity, RR (interval between successive R waves on the electrocardiogram) variability, Valsalva ratio, orthostatic adjustment ratio, and phase II:IV blood pressure ratio (II:IV) of the Valsalva manoeuvre were measured. All autonomic tests were compared with those of 26 healthy volunteers (19 female, mean age 37 years).
  
  
  RESULTS
  Twenty nine of 49 patients were symptomatically improved. Treatment reduced those with < or =3 bowel actions per week (27 v 9, pre v post), need to strain (26 v 9), and laxative or suppository use (34 v 9). Biofeedback reduced retained markers by 32% in those with slow transit and by 20% in those with normal transit. Twenty two had slow transit before treatment-14 felt symptomatic improvement of whom 13 developed normal transit. There was a significantly greater increase in rectal mucosal blood flow in patients who subjectively improved compared with those who did not (29% v 7%; p<0.03) and in those with improved bowel frequency (33% v 9%, increased v unchanged bowel frequency; p<0.05). Thirty five patients had abnormal RR variability and 33 an abnormal Valsalva ratio; one had an abnormal orthostatic adjustment ratio and one an abnormal II:IV ratio. None of the general cardiorespiratory autonomic reflexes was changed by treatment.
  
  
  CONCLUSIONS
  Biofeedback treatment affects more than the pelvic floor. Successful outcome after biofeedback treatment is associated with improved activity of the direct cerebral innervation to the gut and improved gut transit. This effect is gut specific; cardiovascular autonomic reflexes were not altered.
authors.affiliation: St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
authors.forename: A V
authors.initials: AV
authors.lastname: Emmanuel
authors.forename: M A
authors.initials: MA
authors.lastname: Kamm
mesh_terms: D000293:Adolescent; D000328:Adult; D001341:Autonomic Nervous System / Q000503:physiopathology; D001676:Biofeedback, Psychology / Q000379:methods*; D001794:Blood Pressure / Q000502:physiology; D016022:Case-Control Studies; D003248:Constipation / Q000503:physiopathology / Q000628:therapy*; D004562:Electrocardiography; D004576:Electromyography; D005260:Female; D005772:Gastrointestinal Transit / Q000502:physiology*; D006801:Humans; D007413:Intestinal Mucosa / Q000098:blood supply; D007422:Intestines / Q000294:innervation*; D017078:Laser-Doppler Flowmetry; D008297:Male; D008875:Middle Aged; D016011:Normal Distribution; D011446:Prospective Studies; D018667:Tilt-Table Test; D016896:Treatment Outcome; D014636:Valsalva Maneuver / Q000502:physiology