WHAT IS BIOFEEDBACK TREATMENT FOR BOWEL DYSFUNCTION? Sr Sue Ryder Pelvic Floor Specialist Nurse

WHAT IS BIOFEEDBACK TREATMENT FOR BOWEL DYSFUNCTION? Sr Sue Ryder Pelvic Floor Specialist Nurse

Assessment is so important Patients with Bowel dysfunction require an extensive assessment to establish a diagnosis, highlight key points that help the health professional plan the most suitable treatments and management strategies Appointments 1 hour (or more sometimes) make time to get the whole picture, discuss relevant investigation results, previous strategies and why they failed Patients fill in at home a 6 page detailed bowel assessment form - they often add an essay as they have the time Complete a 7 day diet and bowel diary

What is Biofeedback Treatment? Pelvic floor biofeedback therapy is a type of physical therapy that can help men and women to learn how to contract and relax the pelvic floor muscles. It is used for patients who have bladder and/or bowel incontinence, difficult defaecation caused by abnormal pelvic muscle contraction and pelvic floor dysfunction. Patients attend between 3-6 sessions, 1 a month for 3-5 months with a therapist (Specialist Nurse/ Physio/ Physiologist who is specially trained in pelvic floor therapy.

How does pelvic floor biofeedback therapy work? Pelvic floor biofeedback therapy works by training the brain and pelvic muscles to work together to tighten and relax the pelvic floor muscles. Sensors in the vagina or rectum measure the contraction and relaxation of the muscles and patients get visual cues on a computer monitor so that they can learn to better use these muscles. In many cases patients have tried pelvic floor exercises without success, but they have not been contracting the correct muscles or they have been contracting them incorrectly. Many patients symptoms improve following structured pelvic floor biofeedback therapy.

Sensory biofeedback Digital vaginal examination/ palpation Vaginal cones/weights/ Amielle dilators Digital rectal examination Rectal dilators

Relaxation biofeedback Teach anal sphincter, pelvic floor and abdominal muscle relaxation Focus on importance of calm taking your time STOP RUSHING AROUND Teach diaphragmatic and abdominal breathing exercises (practice one now)

Pressure biofeedback Perineometry Rectal balloons assess onset, urge and maximum rectal sensation using millilitre's mls of air. Assess and record both abdominal and rectal propulsion, none, weak, poor, strong etc Then we teach correct abdominal brace and bulge technique Patients are then to practice this each defaecation to improve abdominal-anorectal co-ordination

Ultrasonic biofeedback Trans abdominal ultrasonography Post void bladder scanning

Electromyographic EMG biofeedback

Electromyographic EMG biofeedback Biofeedback units generally provide either visual or auditory feedback relative to the quantity of electrical activity - which is measured in Microvolts μv Visual feedback uses lights, bars, analogue or digital measurements Auditory feedback uses increasing or decreasing tones, buzzing, beeping or clicking

S(SURFACE) EMG Recordings

S EMG signal analysis Baseline or resting level: the level of SEMG when the muscle is totally relaxed. It is generally accepted that the SEMG of a muscle at rest should be below 5μV. Averaged contraction (mean of SEMG during contraction): this is a good indicator of the level of muscle strength and endurance (while performing an isometric contraction). Peak or maximum: this is the maximum SEMG amplitude the muscle can generate. Variability: is a good indicator of the neuromuscular stability.

SEMG signal analysis

SEMG unhealthy muscle The resting level is too high The level of contraction is very low The muscle shows instability

SEMG healthy muscle Resting level is low onset and release are quick and the contraction is high

Biofeedback progress report

Rectum & Anal Canal Stores waste material Rectum wider in diameter -approx 15cm length Absorbs water & electrolytes 500-2000mls per day Habitat for micro-organisms - e coli Anal canal 2 6 cm Anal canal has a very important role in the maintenance of faecal continence (valve) It controls rectal emptying Surrounded by two sphincter mechanisms -Internal & External

Internal IAS & External EAS anal sphincters IAS contributes significantly to resting pressure of anal canal 80% IAS has continuous electrical activity (tonically contracted) IAS has reduced activity with rectal distension (rectoanal inhibitory reflex) EAS is striated muscle innervated pudendal nerve EAS Voluntary contractable, relaxable & fatigable Rectal distension results in increased EAS activity helps maintain continence during internal anal sphincter relaxation

Anorectal sensation and sphincter function during defaecation Contents progressively fill rectum Critical level of filling triggers conscious perception EAS contracted (sub-conscious) as IAS begins to relax Appropriate social context sought (conscious!) and await next giant migrating peristaltic contraction IAS remains relaxed; EAS now relaxes Bolus further relaxes EAS by traction After voiding EAS snaps shut

Normal Defaecation Needs higher than hips Lean forward and put elbows on knees Bulge abdomen Straighten spine

Pelvic Floor Muscles In the rectum the Pelvic Floor Muscles (Levator ani, Puborectalis) regulate faecal retention & defecation Puborectalis suspends the rectosigmoid junction like a sling and facilitates voluntary stool retention Puborectalis and EAS must both voluntary relax, pelvic floor muscles descend to straighten anorectal angle for defaecation

Puborectalis sling

Female pelvic floor muscles

Male pelvic floor muscles

Importance of Pelvic Floor & anal sphincter exercises Prevents urinary and faecal incontinence Exercises increase strength and tone Increases blood flow which increases lubrication Increases sexual pleasure, prevents erectile dysfunction Prevents genital prolapse Supports spine and controls abdominal pressure

Other elements to Biofeedback It s a step up programme Always start with the basic advice (don t presume they re done it) only when that s tried and failed step up I ALWAYS RE-ITERATE IMPORTNCE TO KEEP ON BASIC STEPS AS WE PROGRESS UP 1. A healthy balanced diet 3 meals a day, good neutral fluid intake and some weekly exercise yoga, pilates or just a bit of walking if unfit

Lifestyle and Dietary Advice Fibre Content of Foods General recommendations Dietary fibre: 18 to 30 g per day. Fluid intake: 1.5 to 2 litres per day. Fruit and vegetables: 5 portions per day.

Soluble and Insoluble Fibre Plants have both, classified by the higher level Soluble fruit, veg, pulses, oats, beans, barley, seeds Insoluble fruit & veg with skins & pips, wholegrain cereals (wheat, rye, rice), nuts & some pulses, seeds Insoluble fibre in particular acts like a sponge absorbs water increases stool weight and size and without fluid cannot do its job and will result in constipation Soluble fibre dissolves in water to form a gel like material as it passes through the gut, gentler for IBS patients

Benefits of fibre in your daily diet Normalises bowel movements Helps maintain bowel health Lowers cholesterol levels Helps control blood sugar levels Aids in achieving healthy weight Prevents colorectal cancer

Exercise It is important to try and exercise regularly but don t overdo it. You should aim for 30 minutes of moderate activity at least five times a week. It helps to vary the type of exercise that you. Try different activities such as swimming, walking, aerobic activities and Pilates, and yoga. Avoid activities that suddenly increase your intraabdominal pressure such as high impact aerobics or jogging/running.

Review medication List everything down and their over the counter meds Do they work? Do they have side effects that affect your bowel? If they are necessary consider a safer and gentler alternative they can discuss this with their GP Most people can cut out a lot of their medication

Normalise stool consistency What is your bowel frequency? Do you have a pattern? What is your stool consistency? Only when dietary and soluble fibre supplements have been tried for a good period but aren t working consider: Laxatives Loperamide

Psychological Factors Feeling up tight Anxiety and depression Type A personalities Busy v sedentary lifestyle Ignoring call to stool Going to often just to try Stress Wanting to go when suits them not their bowel

Peristeen Rectal Irrigation BY COLOPLAST Indications Neurogenic bowel dysfunction e.g. spinal cord injury, spinal bifida, multiple sclerosis. Bowel dysfunction Chronic/slow transit constipation Evacuation difficulties. Chronic faecal incontinence. With success rates of 50-90%

PTNS Percutaneous Tibial Nerve Stimulation Treatment BY UROPLASTY Urgent PC Neuromodulation System The Urgent PC System is a simple, safe and effective, outpatient method of treating urinary urgency, urinary frequency and urge incontinence. Urgent PC is also indicated for the treatment of faecal incontinence. With success rates of 60-80%, this simple, non-surgical treatment is effective, lowrisk and associated with minimal sideeffects. The Urgent PC System consists of the Urgent PC Stimulator and the Urgent PC Lead Set.

Sacral Nerve Stimulation BY MEDTRONIC The InterStim TM neurostimulator is a surgically implanted device that stimulates your sacral nerve with mild electrical pulses. The sacral nerve controls your bladder and bowel and the muscles related to pelvic floor function. With success rates of 70-90% Neuromodulation can eliminate the symptoms of overactive bladder, including urge incontinence, urgencyfrequency, and urinary retention, constipation, pelvic pain and faecal incontinence.

MY LOVES & HATES <3 Golden Linseeds, good fluid intake, healthy diet <3 Patients that read our leaflets and practice our recommendations - its only 5 minutes three times a day and when their on the toilet Opiates, polypharmacy (often not required just sometimes to treat each others side effects) Patients that expect surgery to miraculously cure all ailments, if only we could do that!

My conclusion >12 years of Biofeedback Patient assessment and education with conservative management strategies should be first line treatment EMG is safe, effective, painless and well tolerated. It provides significant additional benefits for some bowel symptoms But it s when all the elements of Biofeedback treatment discussed today are put together like a jigsaw that patients symptoms & QOL finally improve You need a motivated patient and skilled practitioner for it to work! With success rates between 40-75%

Educating your patients about everything affecting their bowel problem is vital to help them improve their symptoms and manage better THANKS FOR LISTENING ANY QUESTIONS? Sue Ryder

40 Sue Ryder March 14

Advanced PC Muscle Training by Tatyana Kozhevnikova http://www.youtube.com/watch?v=t-k6-3sfk1g So far this has over 700,000 hits