title: Integrated low-intensity biofeedback therapy in fecal incontinence: evidence that "good" in-home anal sphincter exercise practice makes perfect.
abstract: BACKGROUND
  Biofeedback therapy (BFT) is an established treatment for fecal incontinence (FI), with access often being restricted to tertiary centers due to resources and the perceived requirement for high-intensity regimes. However, the optimal regime remains unknown. We evaluated outcomes from our low-intensity integrated BFT program in a secondary care center.
  
  
  METHODS
  Outcomes of our BFT service for FI were evaluated retrospectively. Response was defined by ≥50% improvement in FI frequency from baseline or complete continence. Responders were compared to non-responders for factors including symptoms, manometry data, sphincter exercise technique and duration of practice, and the number and frequency of sessions. Where patients dropped out, outcomes and the reason for dropout were obtained retrospectively.
  
  
  RESULTS
  Fecal incontinence patients (n=205, median 62 years, 72% female) attended a median (IQR) 3 (2) BFT sessions with 55 (36) days between visits. Overall, 146/205 (71%) responded with 97/205 (47%) achieving continence. Fecal incontinence frequency improved dramatically in completed cases (P=0.000). While non-response was associated with males (P=0.03) and dropout (P=0.000), "good" anal sphincter exercise technique (P=0.008) and longer in-home practice (P=0.007) and more sessions (P=0.04) were associated with response. Dropout rate was 80/205 (39%), with the reason for dropout being obtained in 80%.
  
  
  CONCLUSIONS
  Despite low-intensity BFT, comparable outcomes to data from tertiary centers were achieved. Our data emphasize the importance of technique and in-home practice of anal sphincter exercises. Customizing BFT intensity based on predictive factors and encouraging in-home practice may optimize outcomes, reduce dropout rates, and rationalize resources.
authors.affiliation: GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK.|Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
authors.forename: D H
authors.initials: DH
authors.lastname: Vasant
authors.affiliation: GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK.
authors.forename: K
authors.initials: K
authors.lastname: Solanki
authors.affiliation: GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK.
authors.forename: S
authors.initials: S
authors.lastname: Balakrishnan
authors.affiliation: GI Physiology and Gastroenterology Departments, Pennine Acute Hospitals NHS Trust, Greater Manchester, UK.
authors.forename: N V
authors.initials: NV
authors.lastname: Radhakrishnan
mesh_terms: D000368:Aged; D001003:Anal Canal / Q000502:physiology*; D001676:Biofeedback, Psychology / Q000379:methods*; D005081:Exercise Therapy / Q000379:methods*; D005242:Fecal Incontinence / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006699:Home Care Services; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
keywords: anorectal manometry; biofeedback therapy; fecal incontinence