Biofeedback therapy in the colon and rectal practice

In coloproctology, biofeedback has been used for more than 20 years to treat patients with fecal incontinence, constipation, and rectal pain. It can be performed in a number of conditions with minimal risk and discomfort. However, it does require the presence of some degree of sphincter contraction and rectal sensitivity. Biofeedback can be time-consuming and demands motivation. The purpose of this paper is to review the indications, methodology, and results of anorectal biofeedback in the treatment of these disorders. Mean success rates for biofeedback range from 72.3% for fecal incontinence of diverse etiology, 68.5% for constipation attributable to paradoxical puborectalis syndrome, and 41.2% for idiopathic rectal pain. However, criteria to define success vary tremendously among researchers and there is a tendency to indicate biofeedback in a myriad of conditions when other therapeutic options, including surgery, fail or are inappropriate. These factors make comparison of the results difficult and reinforce the need for randomized controlled trials and studies assessing long-term follow-up. In summary, biofeedback is a simple, cost-effective, and morbidity-free technique and remains an attractive option, especially considering the complexity of the functional disorders of the colon, rectum, anus, and pelvic floor.     

Pelvic Floor Muscle Biofeedback in the Treatment of Urinary Incontinence: A Literature Review

Biofeedback is efficacious in the training of the pelvic floor musculature in order to enhance continence. This article reviews the anatomy and physiology of micturition as the underlying rationale for pelvic floor muscle biofeedback in the treatment of urinary incontinence. It critically reviews 28 studies published in peer reviewed journals from 1975 to 2005 that were prospective, randomized studies with parametric statistical analyses, operationally defined patient selection criteria, treatment protocols and outcome measures. The overall mean treatment improvement for patients undergoing biofeedback for urinary incontinence was 72.61%. In 21 of 35 (60%) paired comparisons, biofeedback demonstrated superior symptomatic outcome to control or alternate treatment groups. Larger studies and a standardization of technology and methodology are required for more conclusive determinations.     

Biofeedback Treatment for Headache Disorders: A Comprehensive Efficacy Review

The aim of the present review was to critically evaluate the documented evidence regarding the efficacy of biofeedback for the two most prevalent headache conditions––migraine and tension-type headache. Drawing upon two recently published meta-analyses, data from 150 outcome studies, including randomized controlled trials as well as uncontrolled quasi-experimental designs, were screened. Of these, 94 studies were selected for inclusion according to predefined criteria. Meta-analytic integrations were carried out separately for the two conditions of interest. The main results were medium-to-large mean effect sizes for biofeedback in adult migraine and tension-type headache patients. Treatment effects remained stable over an average follow-up period of 14 months, both in completer and intention-to-treat analyses. Headache frequency was the primary outcome variable and showed the largest improvements. Further significant effects were shown for perceived self-efficacy, symptoms of anxiety and depression, and medication consumption. Reduced muscle tension in pain related areas was observed in electromyographic feedback for tension-type headache. Biofeedback was more effective than waiting list and headache monitoring conditions in all cases, while electromyographic feedback for tension-type headache showed additional significant effects over placebo and relaxation therapies. Levels of efficacy (migraine: efficacious, level 4; tension-type headache: efficacious and specific, level 5) and recommendations for future research are provided.

The Use of Thermal Biofeedback in the Treatment of Pain Associated with Endometriosis: Preliminary Findings

Endometriosis is a common gynecological disease that causes marked physical and emotional distress in lives of women, resulting in dysmenorrhea, pain, or both throughout the menstrual cycle in over 96% of cases. A multiple case study design (N = 5) was employed to investigate the use of thermal biofeedback in the treatment of pain associated with endometriosis. The majority of participants (4 out of 5) were able to demonstrate mastery over hand temperature through thermal biofeedback. Of those participants, significant reductions in various aspects of pain were observed by the end of the study; one had a significant increase in Life Control; two had reductions in Pain Severity; three had a decrease in Affective Distress; and all 4 demonstrated reduction in Life Interference, as measured by the West Haven-Yale Multidimensional Pain Inventory. This is a preliminary study with a small sample size and without a control sample; hence, the results are considered only as suggestive of the potential use of biofeedback therapy in alleviating pain and associated symptomatology related to endometriosis. Further research is warranted.     

Respiratory Sinus Arrhythmia Versus Neck/Trapezius EMG and Incentive Inspirometry Biofeedback for Asthma: A Pilot Study

This pilot study compared biofeedback to increase respiratory sinus arrhythmia (RSA) with EMG and incentive inspirometry biofeedback in asthmatic adults. A three-group design (Waiting List Control n = 5, RSA biofeedback n = 6, and EMG biofeedback n = 6) was used. Six sessions of training were given in each of the biofeedback groups. In each of three testing sessions, five min. of respiratory resistance and EKG were obtained before and after a 20-min biofeedback session. Additional five-min epochs of data were collected at the beginning and end of the biofeedback period (or, in the control group, self-relaxation). Decreases in respiratory impedance occurred only in the RSA biofeedback group. Traub-Hering-Mayer (THM) waves (.03-.12 Hz) in heart period increased significantly in amplitude during RSA biofeedback. Subjects did not report significantly more relaxation during EMG or RSA biofeedback than during the control condition. However, decreases in pulmonary impedance, across groups, were associated with increases in relaxation. The results are consistent with Vaschillo's theory that RSA biofeedback exercises homeostatic autonomic reflex mechanisms through increasing the amplitude of cardiac oscillations. However, deep breathing during RSA biofeedback is a possible alternate explanation.     

Effects of Biofeedback in Phonatory Disorders and Phonatory Performance: A Systematic Literature Review

The purpose of this article was to systematically review the literature on the effects of biofeedback therapy in the domain of phonatory disorders and phonatory performance, using studies in peer-reviewed journals. An extensive definition of biofeedback is given and its place in voice treatment is defined. Eighteen group or case studies or reports considering the effects of electromyographic, laryngoscopic and acoustic biofeedback in dysphonic patients (hyperfunctional voice disorders, hypofunctional voice disorders, psychogenic voice disorder, laryngeal trauma, total laryngectomy, vocal cord dysfunction) and participants with normal voices are included and an analysis of procedure as well as research design and results is presented. The usefulness of biofeedback in phonatory disorders and performance was to be interpreted based on tendencies, since there is a lack of randomized controlled efficacy studies. In only 3 of 18 studies (16.7%) did biofeedback therapy fail to improve voice quality or not result in better results than other forms of therapy. Recommendations for improved methodologies are made, which include the use of acoustic voice quality parameters.     

Melatonin for the Early Treatment of COVID-19: A Narrative Review of Current Evidence and Possible Efficacy

ObjectiveTo discuss the use of melatonin as an early treatment option on the first day of diagnosis for COVID-19.MethodsMedical Subject Headings terms “COVID-19” and “viral diseases” were manually searched on PubMed, and relevant articles were included.ResultsThe results showed that melatonin acts to reduce reactive oxygen species–mediated damage, cytokine-induced inflammation, and lymphopenia in viral diseases similar to COVID-19.ConclusionThese conclusions provide evidence for potential benefits in melatonin use for COVID-19 treatment as early as the day of diagnosis.     

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.