title: Biofeedback therapy for defecatory dysfunction: "real life" experience.
abstract: BACKGROUND
  Biofeedback therapy (BF) is a well-established treatment modality for patients with dyssynergic defecation and fecal incontinence (FI). Randomized controlled trials from highly specialized tertiary care centers report response rates of 70% to 80% for dyssynergic defecation and 55% to 75% for FI. Whether this therapy is as successful outside of clinical trials or specialized biofeedback referral centers remains unclear.
  
  
  OBJECTIVE
  Our primary aim was to determine what percentage of patients referred for BF actually complete therapy and identify barriers to treatment. Our secondary aim was to determine the clinical response rate in a heterogeneous population of patients undergoing BF at our institution and a variety of regional locations.
  
  
  METHODS
  We retrospectively reviewed patients who underwent high resolution anorectal manometry between 2007 and 2010 for symptoms of defecatory dysfunction. BF was recommended at the time of manometry analysis based on findings of dyssynergy, impaired or heightened rectal sensation, or poor augmentation of sphincter on squeeze maneuvers. Clinical response was recorded after a course of BF (≥ 5 sessions).
  
  
  RESULTS
  Two hundred three patients (78% female, 72% white; median age 52) underwent anorectal manometry for symptoms of constipation (130), FI (54), combination (12), and rectal pain (7). BF was recommended in 119 cases (58.6%): constipation (80), FI (27), combination (9), and rectal pain (3). Only 39 out of 80 (48%) patients with constipation ultimately underwent BF. Of the 27 FI cases, only 12 (44%) patients underwent BF. Barriers to BF included lack of insurance coverage, distance to local treatment facilities, and acute medical issues taking precedence. Of those who underwent at least 5 BF sessions, subjective short-term response rates based on patient opinion were 17/28 (60%) in the constipation group and 8/10 (80%) in the FI group. Age, sex, and race had no effect on whether the patients attended biofeedback or whether they responded to treatment. The location of BF also did not predict response to therapy.
  
  
  CONCLUSIONS
  In a heterogeneous patient population, less than half of patients recommended for BF ultimately underwent therapy. Despite this, the response rates in this small population undergoing BF in the "real world" are only slightly less than published randomized control trials. Prospective studies are warranted to further elucidate and eliminate barriers to BF, especially given that "real world" BF response rates may be comparable with those seen in clinical trials.
authors: Division of Gastroenterology & Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
authors: Daniela
authors: D
authors: Jodorkovsky
authors: Kerry B
authors: KB
authors: Dunbar
authors: Susan L
authors: SL
authors: Gearhart
authors: Ellen M
authors: EM
authors: Stein
authors: John O
authors: JO
authors: Clarke
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal; D001676:Biofeedback, Psychology / Q000379:methods*; D003248:Constipation / Q000628:therapy*; D003672:Defecation / Q000502:physiology*; D005242:Fecal Incontinence / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D012007:Rectum; D012017:Referral and Consultation; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult