Biofeedback training in treatment of childhood constipation: a randomised controlled study

doi:10.1016/S0140-6736(96)03206-0

The Lancet

Volume 348, Issue 9030, 21 September 1996, Pages 776-780

https://doi.org/10.1016/S0140-6736(96)03206-0 Get rights and content

Summary

Background

Because abnormal defaecation dynamics, which can be modified by biofeedback, are considered to be the underlying problem in constipation, biofeedback training may be a useful treatment for constipation. This treatment has mainly been studied in uncontrolled trials. We evaluated defaecation dynamics and clinical outcome in chronically constipated children in a randomised study comparing conventional treatment and conventional treatment with biofeedback training.

Methods

Patients, 5 to 16 years old, were referred to the Academic Medical Center in Amsterdam by general practitioners, school doctors, paediatricians, and psychiatrists. They had to fulfil at least two of four criteria for paediatric constipation and were included if they had been treated medically for at least one month before randomisation. Patients had a medical history, abdominal and rectal examination, and anorectal manometry at the start and end of the 6–week intervention period. The conventional group received laxative treatment with additional dietary advice, toilet training, and maintenance of a diary of bowel habits. The biofeedback group received the same conventional treatment and additionally five biofeedback training sessions. During the first 3 weeks, patients visited the outpatient clinic weekly; two subsequent visits were twice monthly.

Findings

94 patients were randomised to conventional treatment (CT) and 98 to conventional treatment with additional biofeedback training (CT+BF). Normal defaecation dynamics increased in the CT group from 41% to 52% (not significant) and in the CT+BF group from 38% to 86% (p=0·01). At 6 weeks, more patients in the CT+BF group showed normal defaecation dynamics, compared to the CT group (p<0·001). This result was unaltered by controlling for baseline status in a logistic regression model. At 1 year, successful treatment (defaecation frequency 3=3/week, soiling and/or encopresis <2/month, and no laxatives) was accomplished in 59% of the CT and 50% of the CT+BF group (p=0·24). The results were maintained after 11/2 years follow-up. No association was found between achievement of normal defaecation dynamics and clinical outcome.

Interpretation

Additional biofeedback training compared to conventional therapy did not result in higher success rates in chronically constipated children. Furthermore, achievement of normal defaecation dynamics was not associated with success: abnormal defaecation dynamics seem not to play a crucial role in the pathogenesis of childhood constipation. Intensive conventional laxative treatment should remain the first choice in chronically constipated children.

Introduction

Constipation is common in children, accounting for about 3% of consultations in an average paediatric practice and as much as 25% in a paediatric gastroenterology clinic.¹ Conventional treatment with adequate fibre and fluid intake, toilet training, laxatives, emollients or enemas, and behavioural therapy is successful in approximately 60% of newly diagnosed patients.² Less favourable outcomes have been noticed in children with chronic constipation.³

The underlying mechanisms responsible for constipation are unknown. Anorectal manometry in constipated patients has shown impaired rectal sensation, inability to defaecate balloons, and abnormal defaecation dynamics.4, 5, 6, 7 Inability to relax the external anal sphincter during defaecation occurs in more than half of constipated patients, and has been implicated as a treatable factor in constipation.8, 9, 10

Biofeedback applications are used to teach muscle relaxation and to modify autonomic dysfunction in blood pressure, pulmonary, and vascular disease.¹¹ Biofeedback training for disorders of defaecation uses anorectal monitoring instruments to amplify selected physiological processes to make physiological information accessible to the patient's consciousness. Biofeedback works in the treatment of adult faecal incontinence,12, 13 and its use for constipation has attracted interest. Studies have reported positive effects of biofeedback training in constipated adults and children, with success rates varying from 55% to 100%.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Most studies were uncontrolled and used highly selected patients. Only three controlled studies have been done in constipated children. In two,15, 19 long-term follow-up showed comparable success rates between study groups. The success of biofeedback was attributed to restoration of normal defaecation dynamics.²⁶ The third study reported a significant greater improvement in children with additional biofeedback compared to laxative treatment alone, but included only 13 children.²⁷

The authors of these studies concluded that biofeedback training in addition to conventional treatment might shorten the treatment of chronically constipated children. However, biofeedback training is expensive, labour intensive, and requires specialised equipment and trained personnel.

We did a large, prospective, randomised study to evaluate the effect of biofeedback training and conventional treatment on defaecation dynamics and outcome in chronically constipated children.

Section snippets

Patients and methods

A two-group, parallel, randomised controlled trial was carried out in children with chronic constipation referred by general practitioners, school doctors, paediatricians, and psychiatrists to the Academic Medical Center of Amsterdam. The study protocol was approved by the medical ethics committee of the hospital. All patients and/or parents gave written informed consent.

Results

334 patients, 5-16 years old attended our gastrointestinal motility unit between January, 1991, and February, 1994. Of these children, 114 were ineligible: 88 had only soiling or encopresis, and 26 children had complaints of recurrent abdominal pain without any other criteria of paediatric constipation. 66 of the remaining 220 patients had received no previous medical treatment; they were treated with laxatives for 4 weeks, enemas, toilet training, and dietary advice. In 23, this treatment was

Discussion

This study was done to evaluate the additional benefit of biofeedback training added to laxative treatment in the treatment of chronic constipation in children who failed oral laxative treatment. We observed a significant improvement in abnormal defaecation dynamics with biofeedback training but no significant clinical improvement. In contrast to other reports, this study achieved similar success rates of approximately 50% at one year follow up in both conventional treatment and conventional

References (35)

V Loening-Baucke
Chronic constipation in children
Gastroenterology
(1993)
VA Loening-Baucke
Abnormal rectoanal function in children recovered from chronic constipation and encopresis
Gastroenterology
(1984)
VA Loening-Baucke et al.
Abnormal anal sphincter response in chronically constipated children
J Pediatr
(1982)
P Meunier et al.
Rectoanal pressures and rectal sensitivity studies in chronic childhood constipation
Gastroenterology
(1979)
V Loening-Baucke
Modulation of abnormal defaecation dynamics by biofeedback treatment in chronically constipated children with encopresis
J Pediatr
(1990)
RD Mercer
Constipation
Pediatr Clin North Am
(1967)
RC Arndorfer et al.
Improved infusion system for intraluminal esophageal manometry
Gastroenterology
(1977)
T Nolan et al.
Randomised trial of laxatives in treatment of childhood encopresis
Lancet
(1991)
FP Abrahamian et al.
Chronic constipation in childhood: a longitudinal study of 186 patients
J Pediatr Gastroenterol Nutr
(1984)
A Staiano et al.
Long-term follow-up of children with chronic idiopathic constipation
Dig Dis Sci
(1994)

A Wald et al.

Anorectal function and continence mechanisms in childhood encopresis

J Pediatr Gastroenterol Nutr

(1986)

HC Kuijpers et al.

The spastic pelvic floor syndrome. A cause of constipation

Dis Colon Rectum

(1985)

V Loening-Baucke

Factors determining outcome in children with chronic constipation and faecal soiling

Gut

(1989)

J Dahl et al.

Behavioural medicine treatment in chronic constipation with paradoxical anal sphincter contraction

Dis Colon Rectum

(1991)

D Linkenhoker

Tools of behavioral medicine: applications of biofeedback treatment for children and adolescents

J Dev Behav Pediatr

(1983)

BT Engel et al.

Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence

N Engl J Med

(1974)

A Wald

Biofeedback therapy for fecal incontinence

Ann Intern Med

(1981)

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A high risks of bias was found in all studies. A meta-analysis on treatment success, including the 3 studies, which investigated the additional effect of biofeedback to laxative treatment,74-76 showed considerable levels of heterogeneity and no evidence for benefit of the addition of biofeedback (Figure 4). Treatment success was defined by authors and reported in all studies.
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ArticlesBiofeedback training in treatment of childhood constipation: a randomised controlled study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Patients and methods

Results

Discussion

Gastroenterology

Gastroenterology

J Pediatr

Gastroenterology

J Pediatr

Pediatr Clin North Am

Gastroenterology

Lancet

Chronic constipation in childhood: a longitudinal study of 186 patients

J Pediatr Gastroenterol Nutr

Long-term follow-up of children with chronic idiopathic constipation

Dig Dis Sci

Anorectal function and continence mechanisms in childhood encopresis

J Pediatr Gastroenterol Nutr

The spastic pelvic floor syndrome. A cause of constipation

Dis Colon Rectum

Factors determining outcome in children with chronic constipation and faecal soiling

Gut

Behavioural medicine treatment in chronic constipation with paradoxical anal sphincter contraction

Dis Colon Rectum

Tools of behavioral medicine: applications of biofeedback treatment for children and adolescents

J Dev Behav Pediatr

Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence

N Engl J Med

Biofeedback therapy for fecal incontinence

Ann Intern Med

Articles
Biofeedback training in treatment of childhood constipation: a randomised controlled study